The Placebo Effect

[Ziggurat]

Err.... No, not really. Pain is a signal that comes down a nerve.

No, it isn't. The signal coming down the nerve is just a signal. It isn't pain until after it's been processed by the brain. And the only access we have to it after it's been processed is what people report. There is nothing else. There cannot be anything else until we invent mind reading.

But anyway, yeah, sure, some processing is involved between a pressure receptor firing in your hip and your brain getting a pain value. But it still gets A value at the end of the day. Is it any better at comparing it with the value from yesterday than for any other signal?

Yes. Because again, what we care about is the subjective experience, NOT some objective external reality. People's unreliability in correlating their subjective experience to objective external reality doesn't matter when it's the subjective experience we care about and not that external reality.

 

[HansMustermann]

I guess I'm not explaining my point well enough. Let's try more structured and concise.

The problem isn't "pain is an experience". The problem is that the following are 4 very different things:

1. the experience,

2. the MEMORY of an unquantifiable, undescribable experience

3. the ability to COMPARE memories of such unquantifiable, undescribable experiences

4. how you REPORT such

Even going "pain is the experience" doesn't cover #2, #3 and #4 at all.

And the fact that we're crap at #2, #3 and #4 is well proven by now.

E.g., since theprestige brought up colours, that will do nicely to illustrate #3. Because there are actual studies that show that if you don't actually have a different word for different hues, i.e., you can't remember them that way, you absolutely suck at telling whether the colour you remember is the same as the colour in front of you now. As in, if you go to some people who have no different word for "orange", they just call it "red", and you show them an orange card and a range card, sure, everyone will say it's not the same colour. It's a different shade of red, obviously. But if you show them an orange thing today, and tomorrow you show them a red card and ask them if it was this colour, most will say, yeah, it was exactly that colour.

And that doesn't just go for tribes who lack such words. In the very modern western world, virtually everyone who doesn't know burgundy as a separate colour, makes the same confusion between burgundy (#800020) and red (#800000). In fact, a lot pretty much feel like #800020 is THE natural red, a lot more so than the actual #800000 red. Yeah, they can tell it's a different qualia if they see both right now, but they suck at comparing it to the qualia they remember from yesterday, if they can't put a different name on it.

E.g., your memory of a subjective sensation being unreliable and changeable depending on what you want to believe, is the whole POINT of the classic cognitive dissonance experiments. You know, the one where where you have to turn a knob by one degree every X minutes, or to turn pegs in a peg board for an hour, or such. Yeah, boredom is the experience too, there is no quantifiable value, bla, bla, bla. But if at the end of the day,

1. my experience may be that I was bored out of my skull, but

2. how I REMEMBER it after the cognitive dissonance kicked in might be that, actually, it wasn't too bad

And if we add what we know about reporting other things,

4. how I REPORT it may be that it was actually a nice and educational experience, e.g., if I get the impression that that's what the guy polling me wants to hear, or that's what the other group members are reporting, or any of the other KNOWN factors that distort such reports.

So you can stop hammering on "but the pain is the experience." Again, that covers #1. It does NOT cover #2, #3 or #4 AT ALL.

 

[Darat]

...snip...

I think it’s far more likely we will gain a greater understanding of the psychological factors at play and take a multifaceted approach to pain management.

That's been happening in the English NHS for quite some time, started up in Liverpool a few decades back now. It's now recognised that chronic pain shouldn't only be treated with medicine and surgery, often it is as much about helping someone live a good life, with their pain and finding a balance between treatments and quality of life.

I know from discussions here regarding treatment of chronic pain that the USA's medical system (as a generalisation) is quite behind the curve on this.

 

[dann]

Indeed!
Opioids III: The Sacklers: Last Week Tonight with John Oliver (Aug. 9, 2021)

 

[theprestige]

I guess I'm not explaining my point well enough. Let's try more structured and concise.

The problem isn't "pain is an experience". The problem is that the following are 4 very different things:

1. the experience,

2. the MEMORY of an unquantifiable, undescribable experience

3. the ability to COMPARE memories of such unquantifiable, undescribable experiences

4. how you REPORT such

Even going "pain is the experience" doesn't cover #2, #3 and #4 at all.

And the fact that we're crap at #2, #3 and #4 is well proven by now.

E.g., since theprestige brought up colours, that will do nicely to illustrate #3. Because there are actual studies that show that if you don't actually have a different word for different hues, i.e., you can't remember them that way, you absolutely suck at telling whether the colour you remember is the same as the colour in front of you now. As in, if you go to some people who have no different word for "orange", they just call it "red", and you show them an orange card and a range card, sure, everyone will say it's not the same colour. It's a different shade of red, obviously. But if you show them an orange thing today, and tomorrow you show them a red card and ask them if it was this colour, most will say, yeah, it was exactly that colour.

And that doesn't just go for tribes who lack such words. In the very modern western world, virtually everyone who doesn't know burgundy as a separate colour, makes the same confusion between burgundy (#800020) and red (#800000). In fact, a lot pretty much feel like #800020 is THE natural red, a lot more so than the actual #800000 red. Yeah, they can tell it's a different qualia if they see both right now, but they suck at comparing it to the qualia they remember from yesterday, if they can't put a different name on it.

E.g., your memory of a subjective sensation being unreliable and changeable depending on what you want to believe, is the whole POINT of the classic cognitive dissonance experiments. You know, the one where where you have to turn a knob by one degree every X minutes, or to turn pegs in a peg board for an hour, or such. Yeah, boredom is the experience too, there is no quantifiable value, bla, bla, bla. But if at the end of the day,

1. my experience may be that I was bored out of my skull, but

2. how I REMEMBER it after the cognitive dissonance kicked in might be that, actually, it wasn't too bad

And if we add what we know about reporting other things,

4. how I REPORT it may be that it was actually a nice and educational experience, e.g., if I get the impression that that's what the guy polling me wants to hear, or that's what the other group members are reporting, or any of the other KNOWN factors that distort such reports.

So you can stop hammering on "but the pain is the experience." Again, that covers #1. It does NOT cover #2, #3 or #4 AT ALL.

So what's the practical application for the diagnosis and treatment of pain? What's the practical application of all this, for the study and measurement of pain? What do you recommend?

 

[HansMustermann]

So what's the practical application for the diagnosis and treatment of pain? What's the practical application of all this, for the study and measurement of pain? What do you recommend?

As I've already told you: compare it to the known effects before deciding that all the difference is placebo actually working.

Besides, you're still in the wrong thread if you want it to be at the 'pragmatic' hillbilly level of "Offer them some aspirin." (As per your message #51.) We're talking about stuff like determining whether to offer them an aspirin, a placebo, or surgery. You'd think that surgery is invasive enough to kinda be important to know the real effect of all three. But at any rate, when we're talking about a study, we're already past the level of being 'pragmatic' and just trying to "Offer them some aspirin."

 

[HansMustermann]

BTW, not that it would matter anyway. I'm still not impressed by your relentless pursue of trying to stop people from thinking too much about this or that, or god forbid, touch topics that were also at some point touched by philosophy. I can talk about whatever the hell I want, whether it has immediate practical applications or not, and I don't need the approval from you or any other internet non-intellectual that's bothered by it.

Yes, there are lots of topics that lack any immediate pragmatic application. Especially in the science forum.

E.g., GR frame dragging is utterly devoid of any pragmatic applications at the moment. Other than in one experiment where we had to build special probes to even detect it at all, it's orders of magnitude lower than the margin of error for just about anything we can observe up there. We still can and did discuss it in its own thread.

E.g., Hawking Radiation is even more useless at the moment from a pragmatic point of view. We haven't even ever detected it. I mean even for frame dragging we have that one experiment that actually observed it, for Hawking Radiation we have exactly none. We literally can't build anything based on that knowledge, not even a special probe to detect it, and we can't use it to explain anything we've observed up there. But guess what? We can still talk about it.

Etc.

And if people discussing things that may not pass your immediate pragmatism criterion bothers you, that's your problem, not everyone else's.

Really, you have a back button up there. If any discussion is getting too philosophical for you, you can use it.

 

[psionl0]

That implies that the placebo is doing “something.”

It says no such thing. It is just a recognition of the fact that humans are prone to suggestion. They can even be talked into feeling sick (the "nocebo" effect).

Of course, nobody will admit to being prone to suggestion so a lot of skeptics will deny that the placebo effect exists.

 

[psionl0]

Undoubtedly. But it's also, as I said, uncontrolled variables. It's also the idea that you take a pill when the pain is worst, but because you take it when it's at the top of the bell curve, as it were. The pain goes down not because of the intervention, but because it was going to go down anyway.

This and a host of other factors contribute to the "powerful placebo" effect.

Er .. paracetamol is not a placebo. It is an actual pain inhibitor. If you are going to deny that there is anything such as a real pain blocker then you will lose all credibility.

 

[Ziggurat]

I guess I'm not explaining my point well enough. Let's try more structured and concise.

The problem isn't "pain is an experience". The problem is that the following are 4 very different things:

1. the experience,

2. the MEMORY of an unquantifiable, undescribable experience

3. the ability to COMPARE memories of such unquantifiable, undescribable experiences

4. how you REPORT such

Even going "pain is the experience" doesn't cover #2, #3 and #4 at all.

And the fact that we're crap at #2, #3 and #4 is well proven by now.

Why do you think we're bad about #3 and #4? As far as I can tell, the problems with #3 and #4 are all actually problems with #1 (ie, our experience of something isn't an accurate reflection of what we're experiencing). Seriously, how do you test whether someone is bad at reporting their experience? You can only do so by comparing what they report to the external thing. And yeah, that's not accurate. But you cannot conclude that they're bad at reporting their experience, because you cannot distinguish between the experience and the report. You actually have no reason to conclude that their reporting is wrong but their experience is accurate. And everything we know suggests that the problem is at #1, NOT at #4.

And the problems with #2 are avoidable.

 

[theprestige]

BTW, not that it would matter anyway. I'm still not impressed by your relentless pursue of trying to stop people from thinking too much about this or that, or god forbid, touch topics that were also at some point touched by philosophy. I can talk about whatever the hell I want, whether it has immediate practical applications or not, and I don't need the approval from you or any other internet non-intellectual that's bothered by it.

LOL. I'm not trying to get you to stop thinking about it. I just happen to disagree with your thinking on the subject.

You're more than welcome to wax as philosophical as you like about self-reporting not being an ideal measure of qualia. It still won't change the fact that when it comes to pain management qualia is all we have, and self-reporting is the only available tool.

And it still won't change the fact that I think you're wrong about calibrating qualia reporting to other reporting that has an objective reference.

I'm not saying you need to stop having all these ideas I disagree with. I am saying that I reserve the right to disagree with them whenever you bring them up.

 

[theprestige]

Why do you think we're bad about #3 and #4? As far as I can tell, the problems with #3 and #4 are all actually problems with #1 (ie, our experience of something isn't an accurate reflection of what we're experiencing). Seriously, how do you test whether someone is bad at reporting their experience? You can only do so by comparing what they report to the external thing. And yeah, that's not accurate. But you cannot conclude that they're bad at reporting their experience, because you cannot distinguish between the experience and the report. You actually have no reason to conclude that their reporting is wrong but their experience is accurate. And everything we know suggests that the problem is at #1, NOT at #4.

And the problems with #2 are avoidable.

"I feel like my head is being crushed in a vise! I need some pain relief!"

"Good news! Independent and objective observations confirm there is no vise anywhere near your head, let alone crushing it! So you don't really need any pain relief after all!"

 

[HansMustermann]

@Ziggurat
Because we have studies, instead of just rationalizing how we want really hard to believe that those aren't factors.

That's actually where that being able to use an external stimulus comes in handy. Because we can also make sure first that looking at #FF8C00 ("darkorange" as the HTML name goes) is a different qualia than looking at #FF0000 (pure red.) You know, instead of just believing really really hard that if they later confuse the two, it means they had the same subjective experience for both. We can do the scientific thing and engineer the test to first make sure that no, they don't. That was the first part of that study that I mentioned. If you show them the first one on a card, and half a minute later the second one, they can very much tell that it's a different colour. Their subjective experience of it is NOT the same. And you can repeat it as often as you like, and confirm every time, no, they don't experience dark orange as the same as pure red.

It's only when you show them the first today, and the second a day later, that a lot of people who lack different words for both (i.e., they can't remember it as "I saw the orange card yesterday" because they lack the word "orange") start saying that yeah, you showed them the same colour yesterday.

I.e., again, it's not about their qualia / subjective experience RIGHT NOW, nor about the difference between that and the objective value of the stimulus. What matters is that it's two different qualia that we can cause, and yes, they're different qualia. We can test that no it's not the same qualia. It's only the MEMORY of that qualia that turns out to be very mutable, when people are asked to COMPARE anything against it.


Edit: or let's take something without a measurable external stimulus, if that's tripping you up that hard. Let's take the classic cognitive dissonance experiments. The whole point is that you can debrief someone right after they had to turn pegs for an hour, and then ask them about it again after a week, and after being paid 1$ to convince someone else that it's a fun job. And a week later they'll say something completely different than right afterward. One or the other report could be an accurate description of exactly how boring it was, but BOTH can't be true, because they describe a different experience. That memory has changed. That's the whole POINT of those cognitive dissonance experiments.

 

[HansMustermann]

"I feel like my head is being crushed in a vise! I need some pain relief!"

"Good news! Independent and objective observations confirm there is no vise anywhere near your head, let alone crushing it! So you don't really need any pain relief after all!"

Which again just shows that you're in the wrong thread for your usual 'pragmatic anti-intellectual' schtick. Because if you had read what it's about, it does include stuff like, yes, a study about whether it doesn't work just as well to give someone placebo instead of actual pain relief or instead of surgery. I.e., exactly deciding that yeah, exactly, according to some independent and objective study, some people won't get pain relief after all.

Not to mention that if we're talking about studies, then inherently everyone in the control group, yeah, didn't get any actual pain relief. That's what having a control group, and reporting in the test conclusions that the cure used in the other group worked better than placebo, mean.

So your complaint is... what? That a discussion is actually on topic? Or WTH?

 

[Ziggurat]

@Ziggurat
Because we have studies

Studies of what? I've seen studies that show we're bad at remembering things. I've seen studies that show we're bad at differentiating things. I've seen studies that show we're bad at reporting objective external realities.

I have never seen a study that shows we cannot report accurately our own subjective experiences. I don't think there are any such studies.

That's actually where that being able to use an external stimulus comes in handy. Because we can also make sure first that looking at #FF8C00 ("darkorange" as the HTML name goes) is a different qualia than looking at #FF0000 (pure red.) You know, instead of just believing really really hard that if they later confuse the two, it means they had the same subjective experience for both. We can do the scientific thing and engineer the test to first make sure that no, they don't. That was the first part of that study that I mentioned. If you show them the first one on a card, and half a minute later the second one, they can very much tell that it's a different colour. Their subjective experience of it is NOT the same. And you can repeat it as often as you like, and confirm every time, no, they don't experience dark orange as the same as pure red.

It's only when you show them the first today, and the second a day later, that a lot of people who lack different words for both (i.e., they can't remember it as "I saw the orange card yesterday" because they lack the word "orange") start saying that yeah, you showed them the same colour yesterday.

No. You have actually misunderstood something subtle but very important here. What's going on here in the two cases are not the same experience just separated by time. By showing someone two different shades of red, you have given them a different subjective experience than showing them one shade of red. The contrast between the two will make them experience the two shades differently.

It's sort of like the color brown. There's no such thing as brown light, it doesn't exist. Brown is just dark orange, but to experience that as brown and not as orange, you have to be seeing other brighter things which tell you that it's dark. If there's nothing else to compare it to, then brown IS just orange. That contrast is part of the experience. You can even demonstrate this yourself. On your phone or on a tablet, in a well lit room, load up an image that's solid brown. Then take it into a completely pitch-black room, and look at it again. It's orange. Why does it turn from brown to orange? Because in a pitch black room, you have nothing brighter to compare it to to tell you that it's dark.

So no, our experience of color isn't just about the color itself. It never has been. Contrast is vital to our perception of color, and by removing those two similar colors from each other so far in time, your test loses that contrast. It changes the actual perception of the colors. You are not actually just testing how well people recall their subjective experience. Your example doesn't demonstrate what you think it does.

Edit: or let's take something without a measurable external stimulus, if that's tripping you up that hard. Let's take the classic cognitive dissonance experiment. The point is that you can debrief someone right after they had to turn pegs for an hour, and then ask them about it again after a week, and after being paid 1$ to convince someone else that it's a fun job. And a week later they'll say something completely different than right afterward. One or the other report could be an accurate description of exactly how boring it was, but BOTH can't be true, because they describe a different experience. That memory has changed. That's the whole POINT of those cognitive dissonance experiments.

Which is relevant to #2, but not to #3 and #4. And #2 is avoidable.

ETA: back to your dark orange/red thing, the memory problem (ie, #2) is probably an even bigger issue than the contrast, though. And again, #2 is avoidable. But our memory is highly compressed information. And how that information is compressed depends a lot on language, since language helps us categorize things and make distinctions which are important. So our memory compresses the representation of colors we see, often in line with with the language we use for colors. So two different colors may get compressed into one color if there's only one word for both. Which, again, is relevant to #2. But it's got jack **** to do with #3 or #4.

 

[HansMustermann]

Well, yes, now you're getting it. Yes, memory is my biggest problem, and:

A. the language IS a very large part of the problem. We have less trouble remembering things differently or as the same if we have some different word or number to remember. It's only when two or more experiences can at best be described as "uh, it was some kind of shade of red" that you have trouble remembering exactly what shade.

and

B. Well, it's not just literal contrast. They're actually also a very different hue, i.e., angle on a colourwheel. (In fact, the hue is the only difference, since both are 100% brightness and 100% saturated. It may bear the code name of "dark orange" in HTML parlance, but actually it's full brightness and full saturation orange.) But in the more general meaning of 'contrasting' two things, yes, you can tell things apart when you can immediately contrast them to one another. Be it colours, sounds, how tall someone looks, or whatever other non-describable non-quantified thing. I called it compare, you seem to call it contrast, but yes, that's the general idea. But insert a day in between and you no longer have that 'contrast'.

BUT

What I'm saying is that we have the same issue for pain.

A. You don't have a different word for how much it hurt last week before you got the placebo saline injection in your shoulder, vs how much it hurts a week later when you have the next appointment to tell the doctor if it helped.

B. Nor do you have the 'contrast'. Sure, if you had to tell if it hurts more or less after I poke you in the shoulder with a finger, you could tell the difference. If it's actually pressure pain on an inflammation, you'll have your contrast right there when I put some extra pressure on it. My point is that if you insert a week in between, yeah, you don't have that 'contrast' any more.


As for #4, yes, that's covered by different studies and such. And indeed the classic cognitive dissonance experiments are all about #2, so they lack the #3 part too. While each of them is well documented, yes, to the best of my knowledge there is no one experiment that illustrates all 4 in one experiment. It would be nice if there was, but we'll just have to do with what we have.

 

[Ziggurat]

Well, yes, now you're getting it. Yes, memory is my biggest problem

And that problem can be avoided. You don't need to have people remember in order to test placebos.

What I'm saying is that we have the same issue for pain.

Except we don't. The problem you refer to with language causes differences to be ignored. Language may make some differences not show up while others still do, but if you find a difference, it wasn't caused by language. So that's not an argument against placebo effects being real.

As for #4, yes, that's covered by different studies and such.

I don't think it is.

 

[HansMustermann]

And that problem can be avoided. You don't need to have people remember in order to test placebos.

I'm listening. How do you propose to test if people are actually feeling less pain than last week, or hell, since yesterday, without relying on them remembering the sensation from last week?

 

[Ziggurat]

I'm listening. How do you propose to test if people are actually feeling less pain than last week, or hell, since yesterday, without relying on them remembering the sensation from last week?

That's not the test you run.

You take a bunch of people in pain. You have them rate their pain. You give them a treatment (or no treatment). You wait, say, 1 hour. You ask them again to rate their pain.

One person's answers won't mean much. But with a big sample, you can see whether your interventions made a difference. At no point do you need them to compare pain today to pain from last week. You only ever ask about the pain they are experiencing right now.

 

[HansMustermann]

I'll even grant that it might somewhat work at an hour interval, but that's not the thing we're talking about here. We're talking a placebo for surgery, for Pete's sake. You can't ask people in the group that actually got surgery to put the same kind of strain on a shoulder that just got operated, as they did when it hurt before, to see if it already got better. A shoulder that just got cut up and sewn up during the last hour, yeah, you KNOW it's going to hurt more. (Just the inflammation from tissue being cut and sewn is going to activate any of the sleeper nociceptors that weren't already activated.) Nor, really, could you do that with the placebo group without tipping them off that something isn't adding up.

But even without it involving surgery, a lot of these placebo trials involve comparing stuff across weeks or even months. E.g., in this one https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.1002570 one test was the improvement over a 2 WEEKS period, while the second test was over THREE MONTHS. In this one https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-021-04089-9 it's over 4 weeks. Etc. That's quite a bit different from the 1 hour scale you propose, wouldn't you agree?

But generally, even without surgery or even being about pain, the kinds of things that are in placebo trials are not always suited for such immediate comparison. E.g., one such placebo study involved self-reporting how easy it was to fall asleep in patients with insomnia. That's hard to gauge accurately in any case, but more importantly for most people it's going to necessarily mean comparing to something from 24 hours before.