Spring 2011 - Vol.6, No.1
Reflections on Placebos and Factitious Illnesses
Lloyd M. Siegel, M.D.
--Latin:Placere, to please; Facere, to make
The impetus for this article is the editorial in the Fall 2010 issue of JLGH by Dr. Bonchek about the placebo effect and Fibromyalgia. In the Winter 2010 issue that followed, Erich Goldstein suggested that Fibromyalgia offered a perfect vehicle for studies of the possible benefit of the placebo effect. As a practicing Psychiatrist I will discuss the issues of placebos and factitious illnesses from a psychological and existential point-of-view; I believe they have important implications and extrapolations to many fields of Medicine.
ON THE NATURE AND NAMING OF ILLNESS
First, as a demonstration of the power of the word, a concept I will return to at the end of this article, I will notice here several problems and quandaries in the naming of illnesses, an area termed “Medical Nosology.” After pointing out the inherent difficulties of such an enterprise, I will open a brief inquiry into the nature of Factitious Illnesses and Placebos.
All medical classifications of illnesses aim ultimately at aetiologic awareness ( i.e., a reflection of the root causes of an illness). Notwithstanding that simple objective, in actuality we utilize several different modes of medical naming. To cite a few of the many systems:
- Aetiolgic: e.g. Streptococcal Pharyngitis
- Anatomic-pathologic: e.g. Intraductal Cancer of the breast
- Phenomenologic: e.g. Narcissistic Personality
In system #1 we describe unseen but verifiable causes of illness; in #2 we demonstrate somatic-microscopic evidence of illness; in #3 we describe the form or visible expression of an illness.
From another vantage point we can describe illness in terms that reflect the patient’s complaints, symptoms, and signs. Patient is derived from the Latin patior, to suffer. Most patients with illness suffer, though some assuredly do not. Illness may not manifest itself for long periods and during its dormancy we can make no diagnosis, nor does the patient complain. In some sense many ill people are not actually patients because their symptoms are syntonic, i.e. not noticed by them even though the abnormality may affect or be evident to others. Obvious examples of these two phenomena are asymptomatic carriers of illness (typhoid, HIV), and those with certain psychiatric disorders such as Sociopathic Personality. Amidst this maze of complexities let us focus on more limited and specific nosological entities and enlarge our understanding of them and the “naming problem.
At the present time The American Psychiatric Association is in the final stages of preparing to publish its DSM5 (Diagnostic and Statistical Manual 5). This manual is essentially a guidebook for naming and describing mental illnesses. The well-known controversies regarding this new manual are relevant to all problems in the classification of diagnoses and nomenclature, and illustrate the principle that if we cannot accurately name an illness, we probably do not understand its true nature. It follows then that we will not know how to properly treat it. The controversies about the DSM5 encompass such fundamental issues as: How do we define illness? What are the true markers of a veridical (i.e. objectively verifiable) illness? What characteristics separate such terms as syndrome, illness, disease, malady, dysfunction, and disorder? These questions are important because precision of concept is key to understanding diseases and developing approaches to treatment.
Invariably or inevitably, both in controlled scientific studies and in treatments, the question of placebos and placebo effects is related to these same questions, and thus enters into the areas of definition and treatment.
Placebo derives from the Latin verb placere, to please, and appears in our usage as the first person future indicative of the verb, meaning “I will please." This is obviously a positive promise of future benefits from the treatment.
To appreciate “The Placebo Question” we should first explore the power of words to make such a beneficial promise believable. This power of mere words to influence well-being is even more apparent if we examine the negative or antonymic of Placebo Effect which we designate as Maleficent Effect. In introducing this polar contrast we immediately recognize that the negative of placebo involves unknown factors and threats of a poor outcome. We are not referring here to the province of venom-anti-venom, pathogen-antibiotic, gall-stones—cholocystectomy ( i.e. known causes and known cures). Rather, here we enter the region of superstition, nostrums, folk-medicine and a terra incognita of causes and effects; a region of curses, incantations, baleful utterances, or frightening-threatening, all powerful words.
We are all aware that a maleficent utterance or act which portends potential harm can activate that most potent psychic enzyme, “ Fear, “ which may well catalyze a negative outcome. Similarly, invoking a placebo activates that psychic enzyme “Hope” which favors a positive outcome.
The natural ubiquity and widespread susceptibility to maleficence is apparent in the Evil Eye Belief (Malocchio, It.; Ayin Horrah, Heb.), the utterance of curses, and the existence of Voodoo and related cultural belief systems. Fear, which results in the fight or flight response, is a primitive emotion associated with “old brain“ structures; Hope is, in very large part, a cognition associated with “new brain” anatomy (higher level cortical activities).
We may then assume that Fear is the more potent factor and that lower-order animals possess it while higher order Primates, and surely Man, can truly Hope. This Hopeful Capacity is no doubt part of the placebo effect and reaction.
In addition, we may safely state that the quality and nature of the relation between the healer and the patient are of crucial significance in eliciting the Placebo Response, just as the relationship between curser and accursed modulates the level of malevolent response. Also playing a part in the responses are such questions about the intervention as: In what culture?; Who says What to Whom?; and, In what setting and context is the intervention rendered?
Turning now to the problem of factitious illness we may begin again with etymology. The term factitious derives from the Latin verb facere, to make. Again in our common parlance, a Factitious Illness is an entity produced by man rather than natural forces, and may be associated with artificiality and sham. The factitious illness may be regarded as endogenous (i.e. produced by the ill person); exogenous- created by outside influences; or resulting from a combination of these two sources.
Moreover, an entity may be entirely factitious or partly so. In malingering we see the former; in a number of “illnesses” influenced by external forces ( e.g. the media, so-called alternative medicine practitioners, and pharmaceutical interests ) we find the latter.
In these Factitious illnesses of mixed etiology, there exists a vast array of entities, particularly in the field of psychosomatic medicine and somatopsychic disorders. Encouraged by pharmaceutical interests and often by doctors (who bear some responsibility for creating an entire group of iatrogenic illnesses), dysfunctional patients may organize their complaints to conform to named illnesses, e.g. T.M.J. disorders, Restless Leg Syndrome, Peripheral Demyelinating Neuropathy, Lo-T Syndrome, and other questionable disorders. The Pharmaceutical Industry has even sought to define Menopause as an illness for very obvious reasons.
The tendency to define vague, chronic, and pervasive dysfunctions is natural, but becomes the easy target for practitioners and businesses not primarily motivated by science or the desire to treat appropriately.
AN ILLUSTRATIVE EXAMPLE
To focus on a mixed type of factitious illness, allow me to trace the longitudinal history of a single disorder first described by Freud in the 1890’s. In an attempt to separate real mental illness from a more speculative model, Freud thought to name certain illnesses “Actual Neuroses” in contradistinction to the Psychoneuroses. He believed that “Actual Neuroses” come from the present and are due to toxic substances. On the other hand, Psychoneuroses grow out of childhood traumata (Oedipal conflicts, primal scene, etc.) and are for the most part, psychic in nature. Chief amongst this type he placed Neurasthenia. The central core of Neurasthenia was chronic fatigue and weakness, lassitude, lack of spirit and motivation, ennui, and diffuse muscular aches and pains. The patient classically could not precisely describe the specifics of these manifold complaints and the physician could not localize or cogently confirm the nature of the problem by any existing tests. As had occurred after Hippocrates, Aristotle, and Galen, a model of illness described by a genius (Freud) persisted for decades (at least not centuries!) without any progress in diagnosis, testing, or treatment. In fact, Neurasthenia, so carefully described by Freud, had no better or worse history than the “Nuciform Sac .“[*]
However, in the 1970s, 1980s, and 1990s, Freud’s Neurasthenia gained a new life with a new name, Chronic Fatigue Syndrome (Yuppie Flu). This “illness” received wide attention in the media, alternative medicine adherents, and pharmaceutical companies. Nonetheless,like Neurasthenia, it remained vague and essentially enigmatic.
In the first decade of our present century, very few people talk about Chronic Fatigue Syndrome, but a great deal is being said of “The Fibromyalgia Syndrome”. On looking into the prestigious American Heritage Dictionary, one can find virtually identical definitions of “Neurasthenia,” “Chronic Fatigue Syndrome,” and “The Fibromyalgia Syndrome.” Thus, over the course of more than 100 years there has been a slight “spectrum shift” from the almost purely psychic Neurasthenia to the almost purely somatic Fibromyalgia (Chronic Fatigue remaining betwixt and between). Most interestingly, treatment has remained almost completely unchanged, shifting only from verbal anti-anxiety and reassurance (talking treatment) to medicinal therapy (most notably anxiolytic drugs that address the GABA[†] system).
On the basis of many decades of the practice of Psychiatry, as well as Psychoanalytic training (rare nowadays), I strongly suspect we are dealing with the very same illness, morphed and newly named, which will respond to any attention and any success in alleviating anxiety and worry about the complaints. Placebos do play a large part in our treatment of this “illness.” I would further venture that:
-the more factitious the illness, the more potent the placebo; the more real the illness, the less potent the placebo.
Put another way, almost anyone can relieve Fibromyalgia with a vast array of approaches; no one can cure Glioblastoma with any therapy now available.
There remains little doubt that strong connections link factitious illnesses and placebos. From an existential point of view both are Meta-Notions, residing somewhere between a partly understood malady and a partly understood and partly real remedy. We can use this perspective with care in the management of the numerous patients who are difficult to diagnose because they come to us with dysfunctions of this type.
Finally, in answer to Dr. Bonchek's question: “If a patient with Fibromyalgia feels better practicing Tai Chi, even if only because of a Placebo effect, hasn’t the patient benefited?” I would answer both “yes” and “no.”
“Yes”, the individual patient with Fibromyalgia can benefit from Tai Chi. But since Fibromyalgia is a rather protean entity and the placebos are many, I would think that any one of these placebos would also help in other illnesses. Also, and even more significantly, the central power of this type of healing probably derives from the quality of the patient-therapist relationship. As Jerome Frank has pointed out in his seminal work Persuasion and Healing, the prime desideratum in many curative processes lies in a shared personal and cultural belief system re: illness and its cure as agreed upon between patient and physician. Thus the power of shamans, Medicine men, and faith healers, let alone healing messianic types.
As to the “no” in my answer, while we understand that placebos have an invaluable use in medical drug trials, and a very significant use in many treatments, we must at the same time be cautious in esteeming them too highly and note their close connection to all types of factitious illness. If they are offered as legitimate treatments, placebos may inadvertently authenticate factitious illnesses.
As I have said, we may locate both of these entities in the domain of Meta-notions. Or, as the Wittgensteins and German Philologist-philosophers would say (seemingly with more authority - again the power of The Word)-die zwischenvorstellungen: the in-between ideas.
In the meantime we await more elaboration by science of this fascinating duo, factitious illness and placebo treatment.
[*] Nuciform Sac: the putative source of innumerable imaginary illnesses, this structure was excised from wealthy subjects for a hefty fee by surgeon Cutler Walpole, the medical charlatan described by G.B. Shaw in his play The Doctor’s Dilemma (1906).
[†] Gamma-amino butyric acid, an inhibitory neurotransmitter.
 Bonchek, LI. Faint Praise, Imperfect Studies, and the Placebo Effect. J Lanc Gen Hosp. 2010;5:65-67.
 Goldstein, E. Letter to the Editor. J Lanc Gen Hosp. 2010; 5: 136.
 American Heritage Dictionary, 1995. Houghton- Mifflin, 4th Edition
 Frank, JD. Persuasion and Healing, 1978 Shocken Press.
 Wittgenstein, L. Tractatus Logico-Philosophicus, 1922.