The Pharmaceutical Journal
Vol 272 No 7304 p774
19 June 2004

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Placebo or “nocebo”, their action is all in the mind more
Is there a therapeutic role for “ecstasy” in stress and anxiety? more
Health hazards of damp living conditions more
The place of power more

Placebo or “nocebo”, their action is all in the mind

A placebo has been defined as a medicine that has no physiological effect and it was recognised in the 18th century that claims could be made for medicaments that were, in fact, fakes. After such a condemnation the term “placebo” became a dirty word unless it was used to describe an inactive material deliberately designed as a control substance in a clinical trial.

This legitimate use, however, involved another factor, namely that the control substance was, indeed, totally inactive in the physiological sense. It would take a bold experimenter to adopt this as invariably true today, when we accept that mind as well as body plays a role in determining our response to a health menace. That is why, if we do employ a control in assessing the effects of a drug, we must keep it secret from the individual being treated.

It is an interesting study to determine what kind of clinical conditions are susceptible to the placebo effect. Pain is the most evident. Headache, stomach ache, and chronic and acute pains are modified by psychological factors.

Moreover, placebos may cure ulcers of various kinds, and relieve anxiety and depression, presumably by activating the normal body response to inflammatory threats, with the production of endorphins by the pituitary gland. However, there is evidence that unless a recipient believes that a placebo is going to relieve suffering, it will not achieve this end.

Susceptibility to a tribal magician’s curse is an example of the “nocebo” effect

There is another side to this problem, and that is what has been called the “nocebo” effect. This means that a placebo may cause negative rather than positive effects on the recipient. Among manifestations of the nocebo effect is the voodoo ceremony, in which a witch doctor or tribal magician places a curse upon someone. In this instance cursing will have no effect unless the victim is aware that it has occurred and unless he or she is superstitiously susceptible to being cursed.

The same sort of reasoning applies to placebo prescribing, where a mental response determines whether a material has an effect or not.

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Is there a therapeutic role for “ecstasy” in stress and anxiety?

When we talk of ecstasy we mean an exalted state of feeling, the word signifying “standing outside oneself” from the Greek ekstasis. And in 1757 the poet Thomas Gray, of country churchyard fame, wrote of Milton: “Nor second he, that rode sublime / Upon the seraph-wings of Ecstasy / The secrets of th’Abyss to spy.”

Today the drug 3,4-methylenedioxymethamphetamine (MDMA) is the first thing we think of when we hear the word “ecstasy”. In general it has a bad reputation as a dangerous substance of abuse but, as a review published in Nature for 13 May points out, it has another aspect, and it is now being studied as a possible agent for treating anxiety and post-traumatic stress disorder.

It has long been argued by organisations such as the Multidisciplinary Association for Psychedelic Studies in Florida that MDMA is a promising therapeutic tool. A discontinued trial of its potential may be resumed in Spain and other trials are planned in Israel and in Harvard. The main purpose at present is to determine whether the drug will alleviate anxiety and pain in patients who are in the end stages of various forms of cancer.

MDMA is classified as a hallucinogen whose primary function is to alter perception, cognition and mood. Individuals who take the drug recreationally have almost always claimed that they experience euphoria. In conjunction with psychotherapy it is reported that it helps to build trust and self-understanding. Much of its reputation for causing sudden death through dehydration may be due to the sad fact that in the illicit market the identity and potency of tablets said to contain it are in doubt.

The expert opinion is that MDMA decreases brain concentrations of serotonin and damages the connections of serotonin-producing neurons with other cells. It seems certain that it is toxic to those neurons that are responsible for producing serotonin and interacts with other drugs of abuse, as well as inducing the hyperthermia that threatens life. It has a deleterious effect on sleep cycles and offers a temptation for takers to stay awake and active for entire nights. In addition it is suspected to exert adverse cardiovascular effects. Altogether a tricky material!

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Health hazards of damp living conditions

A new report issued by the US Institute of Medicine on the ability of indoor mould to cause or exacerbate respiratory problems can hardly be considered to present any facts that were not known or at least suspected before. However, in the US there are apparently growing concerns about the possible health hazards of damp living conditions.

A commentary published in Science for 28 May discusses some aspects of the problem. It states that about 10 per cent of dwellings are affected by unacceptable dampness, a situation that presents a substantial health issue. Investigation of the evidence has found that moulds growing on indoor surfaces can aggravate asthma in persons suffering from that condition, and provoke coughing and wheezing in otherwise healthy people. But the investigators failed to find a link with other problems concerning breathing. There was a suggestion, but no more, that dampness or visible mould can be responsible for bronchitis or asthma in healthy children living in the affected premises. However, no evidence of a connection with acute pulmonary haemorrhage in infants, or with chronic fatigue, forgetfulness or cancer could be found.

The complexity of the results of damp conditions was held to present a challenge to finding ways of dealing with the problem. In addition to moulds, dampness promotes the activity of bacteria and mites and causes various chemicals to be released from furniture and household fittings.

The examining committee has called for more research into ways of gauging degree of exposure and methods for fighting mouldy growths.

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The place of power

“The only purpose for which power can be rightly exercised over any member of a civilised community against his will is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.”
— John Stuart Mill: ‘On liberty’ (1859).


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