Suggestion/Placebo Effects on Pain: Negative as Well as Positive

Vol. 15 No. 4 April 1998

Journal of Pain and Symptom Management

235

Original Article

Suggestion/Placebo Effects on Pain: Negative as Well as Positive Peter Staats, M.D., Hamid Hekmat, and Arthur Staats Division of Pain Medicine (P.S.), Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland; Department of Psychology, University of Wisconsin-Stevens Point (H.H.), Stevens Point, Wisconsin, and Department of Psychology, University of Hawaii (A.S.), USA

Abstract This study explores the effect of positive and negative placebo suggestions on pain induced by hand exposures to ice water. Thirty-six participants were randomly assigned to one of the following interventions: (a) positive placebo suggestion, (b) negative placebo suggestion, and (c) control. The positive placebo-suggestion participants were given favorable messages about the beneficial effects of ice-water hand immersion. The negative placebo-suggestion group was given messages depicting the negative effects of exposure to ice water. The control groups were given neutral messages about exposure to ice water. Participants rehearsed the messages and focused on them during their second hand exposures. Results indicated that both the positive and negative placebo-suggestion interventions significantly altered participants’ pain threshold, pain tolerance, and pain endurance. Participants exposed to a positive placebo condition tolerated pain better than a neutral condition. Participants exposed to a negative placebo did not tolerate pain as well as participants with a neutral condition. J Pain Symptom Manage 1998;15:235–243.  U.S. Cancer Pain Relief Committee, 1998

Introduction There has been controversy over the placebo effect: what it is, its mechanism of action, and how prevalent it is.1 There is great variability in individual responsiveness to placebo. A placebo efficacy response of as low as 0% to as high as 100% has been reported in the literature.2,3 Beecher originally noted that about 35% of patients in his 11 studies demonstrated a placebo response.4 Several hypotheses have been proposed to account for the efficacy of placebos. First, the placebo is thought to attenuate pain by reducing anxiety.5 Second, the placebo effect may be Address reprint requests to: Peter S. Staats, M.D., Director, Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, 600 North Wolfe Street, Osler 304, Baltimore, Maryland 21287-5354. Accepted for publication: May 31, 1997.  U.S. Cancer Pain Relief Committee, 1998 Published by Elsevier, New York, New York

explained by a history of classical conditioning.6 Placebo events serve as conditioned stimuli and by association acquire the positive emotional responses induced by drugs, therapists, and others within a therapeutic context. The experimental evidence supporting this explanation of placebo effect appears in both animal and human research.7–12 Third, a cognitive– expectancy theory has been offered to account the effects of placebos.13 Within such framework, it is the expectation of what is to occur that determines the response to the placebo. Some investigators have suggested that conditioning factors have primacy over expectancy in mediating the effects of placebos.14,15 However, the primacy of conditioning needs to be demonstrated more convincingly and with greater precision and vigor.16 Finally, the effects of the placebo may also be considered within physiological and biochemi0885-3924/98/$19.00 PII S0885-3924(97)00363-1

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cal models. The endogenous opioid(s) mechanisms may be involved.17–19 Drugs such as naloxone that block the effects of endogenous opioids can inhibit the placebo-induced painrelief in persons suffering from ischemic pain. The physiological explanation may not be independent from the conditioning effect. For example, there are data demonstrating that opioid release induced by morphine injection can be conditioned to neutral orange scent in rats.20 Suggestion is another concept that has been considered in the context of the amelioration and exacerbation of pain.21–29 It, too, is described in different ways. Mostly, it is taken for granted that suggestion involves a type of cognitive process, but the process is usually not specified. The principles that determine the process, the principles by which the process affects pain, and individual differences in the response to suggestion stimuli are seldom described. Placebos and suggestions are ordinarily considered separately. In both cases, however, the fact that there are a variety of imprecise definitions that are not analyzed in terms of basic principles, and are not closely connected to an empirical definition, has impeded any interest in relating the two, despite the similarity of effect on pain. In the present view, placebo and suggestion phenomena have commonalities, and in science it is always valuable when common principles for diverse appearing phenomena can be found. Both phenomena involve the occurrence of stimuli that have the effect of ameliorating pain. In the case of suggestion, the stimuli are social, frequently what is said to the patient. In the case of the placebo, the stimuli tend to be objects, medications, procedures, apparatus, and so on. In neither case does the stimulus involved have a physiologic effect on nociception. But in both cases the stimulus reduces pain. Another study has shown that words can elicit an emotional response that can affect the manner in which a feared stimulus will elicit a negative emotional response.30 The principles that underlie the present approach state that one stimulus that elicits a positive emotional response can modify the negative emotional response elicited by another stimulus (and vice versa).31,32 Both the suggestion and placebo effects can be considered in those terms. To elaborate, one theory of pain has considered that pain involves a negative emotional response;33


pain can be modified by the experience of other stimuli that elicit an emotional response. That is what happens when a suggestion is made that elicits an emotional response; there is an effect on the pain that is being experienced. The placebo effect can be considered in the same terms. One of the features of this framework is that emotional responding has both a positive case and a negative case. Extended to the consideration of placebos and suggestions is the implication is that there should be ‘‘negative placebos’’ (nocebos) and ‘‘negative suggestions,’’ as well as positive. That is, there should be stimuli that have no biological effect on the nociceptive process but that, nevertheless, exacerbate the pain because the stimuli themselves elicit a conditioned negative emotional response. In this study, we explored the effects of two types of intervention on the overt pain behaviors that were made to a pain stimulus (cold pressor pain). The negative placebo suggestion consisted of negative words, the description of the negative effects of exposure to ice-cold water. The positive placebo suggestion was a description of the positive effects of exposure to ice water. The psychological behaviorism theory of pain predicts that the two tactics, which generate diametrically opposing emotional reactions, should have opposite effects on pain behaviors. That is, higher levels of pain threshold, tolerance, and endurance are predicted with the positive placebo-suggestion intervention, and lower levels of pain threshold, pain tolerance, and pain endurance behaviors are expected from applying the negative placebosuggestion condition.

Methods Subjects In exchange for credit, 60 college students were recruited for this project from the University of Wisconsin-Stevens Point human subject pool. Participants were informed that the experiment involved placing their dominant hand in ice water. Participants were prescreened on a medical questionnaire to exclude those with chronic pain, back pain, headaches, mental distress, cardiovascular disorder, asthma, arthritis, and Reynauld disease. Participants were also excluded if they were taking as-


Positive and Negative Suggestion—Placebo

pirin or other analgesic medication, cough medicine, a sedative, a tranquilizer, an antidepressant medication, or alcohol. The ages ranged from 18 to 36. The median age was 19 yrs and the mean age was 21 years (standard deviation 4.3). There were 38 women, and 22 men. The nonparametric Kruskal–Wallis tests indicated that groups were not significantly different from each other in terms of age and gender (P . 1.0).

Procedure

A 41 3 21 cm transparent acrylic tank contained crushed ice and water, which was circulated at a temperature of approximately 1°C. Participants were furnished the informed consent form, a brief medical screening, and mood questionnaires. The hand immersion instructions in this study was similar to those developed by Grimm and Kanfer.34 Briefly, participants were asked to keep their hand immersed long enough for the experimenter to gather data, but to remove their hand when they could no longer tolerate the pain. Participants were asked to communicate to the experimenter the onset of discomfort by saying ‘‘now.’’ As in previous cold-pressor task studies, a ceiling safety level of 5-min maximal submergence was adopted. Before and after each hand immersion, subjects were given sufficient time to warm their hands in a room temperature water bath. Warming time was left at the discretion of each subject. Hand immersion started the timing and hand removal was used to stop the timing. Intervention programs followed immediately after the first hand immersion. After rehearsing placebo suggestion and neutral pain coping tactics, participants submerged their hand in ice water for a second time and furnished pain and mood self-report ratings as in the previous trial. Participants were debriefed at the completion of the experiment. Positive placebo-suggestion intervention (PPI). Participants in the PPI group were given the following message: ‘‘We are studying how people respond to painful conditions. We want to control the conditions for all subjects. We will tell you exactly what to do during this experience. I am going to tell you something about the cold water experience. For most people, there are beneficial effects for having their hand in ice

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water. The positive effects occur during this short period. That’s why we have placed a 5min limit to your hand immersion. Ice water exposure has significant benefits. It improves circulation, exercises blood vessels, strengthens the heart, tightens the skin pores, and cleanses the skin cells. Exposure can also improve temperature and touch sensitivity, and prevent wrinkling of the skin. It can also make people hardy and insensitive to arthritis. Immersion of your hand in cold water is not dangerous to your health as long as it is not done too long. We are going to stop the immersion after 5 min as a precaution. However, there are individual differences in cold tolerance. So be sure and tell us if you experience excessive pain as a result of the cold’’. Participants were asked to rehearse the messages depicting positive aspects of hand immersion and covertly re-state them during their second hand immersion. Negative placebo-suggestion intervention (NPI). Participants were instructed about negative consequences of the hand immersion in ice water. More specifically, they were told: ‘‘We are studying how people respond to painful conditions. We want to control the conditions for all subjects. We will tell you exactly what to do during this experience. I am going to tell you something about the cold water experience. Exposure to ice water can be potentially damaging if exposure to ice water lasts too long. It can cause numbness in hand and fingers, loss of sensation, constriction of blood vessels, decrease blood flow to brain, and induce hypertension; it can promote frost bite, swelling of finger joints, discoloration of finger nails, temporary bruises, premature aging and wrinkling of the skin, and sensory losses. Immersion of your hand in cold water is not dangerous to your health as long as it is not done too long. We are going to stop the immersion after 5 min as a precaution. Participants were asked to rehearse the messages depicting negative aspects of hand immersion and covertly re-state them during their second hand immersion. Control intervention. The control group participants were furnished pain and mood state assessment measures. As in previous groups, the control group participants also submerged

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their dominant hand in ice water on two occasions. Participants were given accurate and yet neutral information about the ice-water experiment. More specifically, participants were told: ‘‘We are studying how people respond to cold conditions. In order to do the study we need to control conditions. To be good subjects, you should not try to do anything special with respect to cold water. Try not to think aloud anything special, or distract yourself. Just participating and following instructions in a neutral manner will yield the best results; results that are unbiased.’’ Participants were told that they are free to withdraw their hand when they wish, but should keep their hand long enough to permit the experimenter to collect pain data. The control group also furnished the pain and mood ratings as the experimental groups. Participants were asked to submerge their hand in a room temperature water bath and to indicate to the experimenter their readiness to proceed with the next hand immersion trial.

ceiling was adopted for safety reasons, and applied at the second exposure.

Measurements

Measures of pain threshold (immersion to pain onset), pain endurance (total duration minus threshold time), and pain tolerance (total duration of hand immersion) were used. These three measures represent highly correlated dimensions of pain.40,41 Logarithmic transformations were performed on the pain threshold, pain tolerance, and pain endurance data to minimize skewness of pain measures and attenuate error variance due to individual differences in reactivity to the cold pressor task. Multivariate and repeated measures univariate analyses of covariance was performed on the pain measures. Unless otherwise stated, the gender of participants served as covariate in the statistical analyses reported. A multivariate repeated measures analysis of covariance (MANCOVA) used the logarithm of pain threshold and pain tolerance and pain endurance as dependent variables. The MANCOVA yielded a significant group effect, Wilks’ Lambda 5 0.40, F(6, 102) 5 9.79, P , 0.001. A significant pain reduction occurred on the second hand immersion as compared to the first, Wilks’ Lambda 5 0.27, F(3, 51) 5 45.38, P , 0.0001, indicating that placebo-suggestion interventions significantly affected pain experience. Repeated measures MANCOVA also yielded a significant interaction effects, Wilks’

Mood measures. Multiple Affect Adjective Checklist (MAACL) was used to assess participants’ mood states.35 The MAACL consists of 132-item adjectives measuring current anxiety, depression, and anger mood states. Participants selected adjectives describing ‘‘their feeling right now.’’ The split-half reliability of the scale ranged from 0.79 for anxiety to 0.92 for depression, and 0.98 for the anger state. The MAACL has demonstrated sensitivity in assessing fluctuations of transient mood states in a number of studies.36–38 Participant’s mood was also assessed using 11-point Likert-type scales. Pain measures. Pain threshold, tolerance, and endurance were also assessed by using a digital stop watch. Pain threshold refers to the onset of hand immersion to the first report of discomfort. Pain tolerance refers to the total duration of hand immersion from entry to withdrawal. Pain endurance refers to duration of hand immersion from entry to withdrawal. Pain endurance refers to duration of hand immersion from the onset of pain threshold to time of the hand withdrawal. Participants who had submerged their hand for more than 3 min as well as those taking analgesic, anxiolytic, or antidepressant medication were excluded. A 5-min

Treatment Credibility The credibility of the intervention programs was assessed by a five-item scale derived from the Borkovec and Nau.39 The item in the treatment-credibility scale of this study measured how logical the pain control intervention was, the level of confidence that the participants displayed toward the intervention, the likelihood of recommending this treatment to a friend, the efficacy of intervention for a different pain (that is, headache, muscular pain), and in a different setting (that is, hospital, clinic). The treatment credibility items were rated on a seven-point bipolar scale. This scale was administered after the second hand immersion to minimize subject awareness of placebo-suggestion interventions.

Results



Lambda 5 0.34, F(6, 102) 5 11.81, P , 0.001, indicating that participants responded differently to the positive placebo-suggestion and the negative placebo suggestion. A MANCOVA planned comparison indicated that positive placebo significantly enhanced pain coping, Wilks’ Lambda 5 0.31, F(3, 51) 5 36.31, P , 0.0001. A MANCOVA planned comparison also indicated that negative placebosuggestion intervention significantly attenuated participant’s pain coping, Wilks’ Lambda 5 0.37, F(3, 51) 5 28.56, P , 0.0001. The control group participants did not show significant changes in pain coping from the first to second hand immersion trial, Wilks’ Lambda 5 0.96, F(3, 51) 5 0.52, P . 0.10. During the Second hand immersion, the positive placebo-suggestion participants displayed superior pain coping as compared to both the negative placebo and the control, Wilks’ Lambda 5 0.70, F(3, 51) 5 7.05, P , 0.001.

Pain Threshold A three-by-two repeated measures univariate ANCOVA was performed on the pain threshold data. A significant group effect, F(2, 56) 5 4.47, P , 0.01, and a significant interaction effect occurred, F(2, 56) 5 36.18, P , 0.001. Results confirmed that the intervention programs were dissimilar on their effect on pain threshold. Planned comparison indicated that the positive placebo-suggestion group raised pain threshold from the first to the second hand immersion, F(1, 56) 5 39.02, P , 0.001. The negative placebo suggestion significantly lowered pain threshold from the first to the second hand immersion, F(1, 56) 5 33.42, P , 0.001. The control group hand immersion threshold also did not change significantly from the first to the second hand immersion, F(1, 56) 5 0.16, P . 0.10. Planned comparison of the second immersion data indicated that the positive placebosuggestion participants had a significantly higher pain threshold than the negative placebo suggestion or the control, F(1, 56) 5 18.80, P , 0.001. Figure 1 plots changes in pain threshold from immersion 1 (Pretreatment rate) to immersion 2 (Posttreatment).

Pain Tolerance A three-by-two repeated measures univariate ANCOVA was also performed on the pain toler-

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Fig. 1. Change in pain threshold from pretest to posttest in the positive placebo, negative placebo, and the control participants.

ance data. There was a non-significant group effect, F(2, 56) 5 1.88, P . 0.10, and a nonsignificant pre-post gain effect, F(1, 56) 5 0.48, P . 0.10. The same univariate ANCOVA, however, yielded a significant interaction effect, indicating that intervention programs had diametrically opposed effects on pain tolerance, F(2, 56) 5 20.41, P , 0.0001. Planned comparison indicated that the positive placebo-suggestion participants increased their tolerance significantly from the first to the second hand immersion, F(1, 56) 5 16.28, P , 0.001. Planned comparison also indicated that the negative placebo-suggestion intervention significantly reduced tolerance from the first to the second hand immersion, F(1, 56) 5 24.95, P , 0.001. The control group did not show significant changes in pain tolerance from immersion 1 trial to immersion 2 trial, F(1, 56) 5 0.06, P . 0.10. Planned comparison also indicated that the positive placebo-suggestion participants had a significantly higher pain tolerance as compared to the negative placebo-suggestion and the control during the second hand immersion trial, F(1, 56) 5 12.93, P , 0.001. Changes in tolerance from pretreatment to posttreatment are plotted in Figure 2.

Pain Endurance Pain endurance was calculated by subtracting threshold from tolerance. Pain endurance refers to the duration of hand immersion from the onset of pain to the withdrawal of the hand from ice water. A three-by-two repeated measures univariate ANCOVA yielded a significant

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Fig. 2. Change in pain tolerance from pretreatment to posttreatment in the positive placebo, negative placebo, and control participants.

Treatment X Groups interaction effect only, F(2, 56) 5 7.79, P , 0.001. Planned comparisons indicated that the positive placebo group showed significantly higher pain endurance during the second hand immersion as compared to the first trial, F(1, 56) 5 9.79, P , 0.01. The negative placebo-suggestion participants had significantly lower pain endurance during the second as compared to the first trial, F(1, 56) 5 5.01, P , 0.05. The control participants did not display significant changes in their pain endurance from the first to the second trial, F(1, 56) 5 0.78, P . 0.10. Changes in endurance from the first immersion to the second immersion trial are plotted in Figure 3. Table 1 summarizes the means and standard deviations for the pain threshold, pain tolerance, and pain endurance.

Treatment Credibility A MANCOVA analysis performed on logical appearance of placebo instructions, confidence


Fig. 3. Change in pain endurance from pretreatment to posttreatment reported by participants receiving placebo interventions as compared to the control.

in treatment, willingness to recommend treatment to other, or undergo the same treatment for a different pain, and the overall perceptiveness of treatment efficacy showed that negative and positive placebo instructions were equally credible and not significantly different from each other, Wilks’ Lambda 5 0.95, F(6, 51) 5 0.45, P . 0.10. Separate univariate analyses of covariance (ANCOVA) performed on the treatment credibility scale confirmed the results of the MANCOVA. A univariate ANCOVA also indicated that groups were not significantly different from each other in their self-report of the therapists’ attractiveness, F(2, 56) 5 0.23, P . 0.10.

Mood A MANCOVA analysis of participants mood state indicated that the experimental and control groups were not significantly different on measures of anxiety, depression and hostility

Table 1 Means and Standard Deviations for Threshold, Tolerance, and Endurance Threshold

Positive Placebo M SD Negative Placebo M SD Control Group M SD M, mean; SD, standard deviation.

Tolerance

Endurance

Pre-

Post-

Pre-

Post-

Pre-

Post-

17.70 12.43

33.85 32.02

61.25 48.74

105.70 87.13

43.55 42.87

71.85 75.96

19.10 8.72

11.90 7.81

67.60 39.44

38.50 21.12

48.50 35.92

23.90 23.24

12.80 10.33

15.70 17.28

52.60 42.85

56.50 56.14

39.80 38.97

40.80 44.87



before the intervention programs were initiated, Wilks’ Lambda 5 0.78, F(6, 52) 5 1.11, P . 0.10. Participants’ self-reports of anxiety, hostility, and depression mood states were analyzed using repeated measures MANCOVA. A repeated measures MANCOVA performed on the mood self-reports indicated that participants’ mood state significantly changed from the first to the second hand immersion trial, Wilks’ Lambda 5 0.74, F(3, 54) 5 6.24, P , 0.001. A univariate repeated measure ANCOVA confirmed that pain intervention programs significantly altered the participants’ level of anxiety from the first to the second hand immersion trial only, F(1, 57) 5 15.49, P , 0.001. Planned comparison indicated that positive placebo suggestion significantly reduced participants’ anxiety, F(1, 57) 5 6.53, P , 0.02. Negative placebo suggestion significantly increased the participant’s anxiety, F(1, 57) 5 7.84, P , 0.01. The control participants’ anxiety did not change significantly, F(1, 57) 5 0.09, P . 0.1. Further, univariate analysis of covariance indicated that placebo intervention did not significantly alter the participants’ anger, F(2, 56) 5 1.50, P . 0.1, and depression, F(1, 56) 5 0.51, P . 0.1. A three-by-two repeated measures univariate ANCOVA was performed on self-reports of worry. A significant Group 3 Trial interaction effect was obtained, F(2, 56) 5 16.93, P , 0.001. Planned comparison indicated that positive placebo suggestion significantly reduced participants’ worry from the pre- to postimmersion trial, F(1, 56) 5 21.63, P , 0.001. The negative placebo suggestion intervention increased participants’ worry score significantly, F(1, 56) 5 12.71, P , 0.001. The control group worry score did not change significantly from the pre- to post-immersion trial, F(1, 56) 5 0.02, P . 0.1. With respect to Perceived Pain Coping Competence, a univariate repeated measures ANCOVAS was performed on participants’ selfreported ability to cope with pain. There was a significant group effect, F(2, 56) 5 4.89, P , 0.01, hand immersion trials effect F(1, 56) 5 3.98, p , 0.05, and an interaction effect, F(1, 56) 5 41.67, P , 0.001. Planned comparison indicated that the positive placebo participants pain coping competency increased significantly, F(1, 56) 5 30.27, P , 0.001. The negative placebo intervention significantly reduced

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participants pain coping competency, F(1, 56) 5 54.59, P , 0.001. The control intervention did not significantly alter participants’ pain coping competency, F(1, 56) 5 2.47, P . 0.10.

Discussion The results of the present study demonstrate that suggestion/placebo interventions significantly influenced the response to acute pain induced by exposure to ice water. The positive placebo intervention significantly increased the pain threshold, pain tolerance, and pain endurance in comparison to the control condition.42–47 These findings are supported by several lines of research. The present study also incorporates the negative suggestion/placebo into the conceptual framework, and the results showed that the negative placebo significantly reduced pain threshold, pain tolerance, and pain endurance. Although the suggestion/placebo stimuli used in the present study were verbal, the type of stimulus employed is, in the present view, inconsequential. We would expect the same results in two groups of subjects given the same medication, if one group had previously been conditioned to have a positive emotional response to it and the other group had been conditioned to have a negative emotional response to it. The essential aspect is the extent to which the stimulus elicits a positive emotional response. A pill can act as a placebo suggestion. The same is true of the words uttered by the physician. The present study indicates that such words can be crucial in the treatment of pain. For just as they can serve a therapeutic effect by decreasing pain and pain behavior, the physician who says things that elicit a negative emotional response in the patient can increase the patient’s pain and the patient’s pain behavior. The participants receiving the positive placebo endured the pain longer and had a greater ability to cope with pain. Such a selfreport may be considered to have a self-esteem (self-concept) value, because the ability to cope with pain is generally considered a positive characteristic. Conversely, those receiving the negative placebo did not perform as well, and their self-report (self-concept) indicated they perceived their lack of coping ability. Interestingly, subjects’ self-perceptions were actually

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influenced by an environmental event—the type of placebo-suggestion experienced—not by the person’s personality. These results have implications for the study of the manner in which pain experience affects self-perceptions or self-concept; patients with chronic pain typically suffer losses in self-esteem. In this study, several measures were taken to minimize the demand characteristics of the procedures. For example, the experimenters did not face the participants during the hand immersion trials, minimizing direct or indirect communication and cues given to the subjects. It may be added in this context that previous studies of the authors and others have specifically addressed the experimental demand issue and have found that words can be employed to elicit emotions without the subjects being aware of the purpose of the experiment.48–50 The fact that all experimental interventions were perceived to be equally logical and credible, as measured by the Borkovec and Nau treatment credibility scale, provided a means of evaluating the control of experimental demand.51 Even the gender of the experimenter was used as a covariate to control for positive influence; there were no significant differences among groups in their ratings of the experimenter attractiveness. The psychological behaviorism theory of pain calls for interrelating the biological study of pain and the behavioral study of pain. The basic principles of the theory state that elicitation of a positive emotional response reduces the individual’s negative emotional state (anxiety). The effect of positive or negative stimuli on the emotional state of the individual directly correlates with the patients pain behaviors. From the present study, we cannot ascertain the biological correlates of this response. Endogenous opioids in the cerebrospinal fluid have also been negatively correlated with human anxiety states.52 Thus, a positive placebo may raise endogenous opioid levels, whereas a nocebo (negative emotional stimulus) may decrease those levels. Further research will need to be done to delineate biological mechanisms involved in the biological–behavioral processes of pain.

Shipyard, and Amend White for their assistance in collecting the experimental data.

Acknowledgment

17. Gracely RH. Evidence for opioid and nonopioid mechanisms of placebo analgesia. Paper presented at the Fourth Annual Meeting of the American Pain Society, 1983.

We wish to thank Rachel Jo Pallen, Susan Heinle, Tammy Albert, Jennifer Miller, Cherry

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