@phdthesis{Reicherts2013,
  author    = {Reicherts, Philipp},
  title     = {Cognitive and Emotional Influences on Placebo Analgesia and Nocebo Hyperalgesia},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-106455},
  school      = {Universit{\"a}t W{\"u}rzburg},
  year      = {2013},
  abstract  = {The perception of pain can be modulated by a variety of factors such as biological/pharmacological treatments as well as potent cognitive and emotional manipulations. Placebo and nocebo effects are among the most prominent examples for such manipulations. Placebo and nocebo manipulations cause reliable psychological and physiological changes, although the administered agent or treatment is inert. The present dissertation aimed at investigating the role of cognitive and emotional influences in the generation of placebo and nocebo effects on pain perception. In addition, the feasibility of solely psychological placebo manipulations to alter the perception of pain was tested. Two commonly discussed preconditions for the generation of placebo and nocebo effects are prior experiences (i.e., past encounter of drug effects) and expectations (i.e., positive or negative attitudes towards an intervention). So far, research on placebo and nocebo effects relied on the administration of sham interventions, which resembled medical treatments like inert pills, creams or injections. However, such experimental procedures deal with confounds due to earlier experiences and expectations resulting from the individual's history with medical interventions. Accordingly, the implementation of a placebo manipulation that is completely new to an individual, seems necessary to disentangle the contribution of experience and expectation for the induction of placebo and nocebo effects. To this end, in Experiment 1 the level of experience and expectation regarding a placebo-nocebo treatment was stepwise manipulated across three different experimental groups. To avoid any resemblances to earlier experiences and individual expectations, a mere psychological placebo-nocebo treatment was chosen that was new to all participants. They were instructed that visual black and white stripe patterns had been found to reliably alter the perception of pain. One group of participants received only the placebo-nocebo instruction (expectation), a second group experienced a placebo-nocebo treatment within a conditioning phase (experience) but no instruction, and a third group received the combination of both that is a placebo-nocebo instruction and a placebo-nocebo conditioning (experience + expectation). It was shown that only the experience + expectation group revealed significantly higher pain ratings and physiological responses during nocebo, compared to placebo trials of the succeeding test phase. These findings demonstrate that the induction of a mere psychological placebo-nocebo effect on pain is in principle possible. Most important, results indicate that such effects most likely rely on both, a positive treatment experience, due to the encounter of an effective intervention (placebo conditioning), and a positive expectation about the intervention (placebo instruction).Besides experience and expectation, the current mood state has been shown to modulate pain and to impact the induction of placebo and nocebo effects. In this vein it has been demonstrated that placebo effects come along with positive affect, while nocebo effects often occur together with elevated feelings of anxiety. To clarify the interaction of emotions and placebo-nocebo manipulations on pain perception, in Experiment 2 the paradigm of Experiment 1 was modified. Instead of black and white stripe patterns, positive and negative emotional pictures were presented, which either cued pain increase (nocebo) or pain decrease (placebo). Two experimental groups were compared, which differed with regard to the instructed contingency of positive pictures serving as placebo and negative pictures serving as nocebo cues or vice versa (congruent vs. incongruent). Results indicate that the differentiation of placebo and nocebo trials (behaviorally and physiologically) was more pronounced for the congruent compared to the incongruent group. However, in the incongruent group, affective pain ratings were also significantly higher for nocebo (positive pictures) than placebo (negative pictures) trials, similar to the congruent group. These findings demonstrate that a placebo-nocebo manipulation is capable to dampen and even reverse the originally pain augmenting effect of negative emotions. The results of Experiment 2 were further corroborated in Experiment 3, when the design was adapted to the fMRI scanner, and again a congruent and an incongruent experimental group were compared. Behavioral, physiological and neurophysiological markers of pain processing revealed a differentiation between nocebo and placebo conditions that was present irrespective of the experimental group. In addition, the fMRI analysis revealed an increased engagement of prefrontal areas for the incongruent group only, supposedly reflecting the reinterpretation or appraisal process when positive pictures were cueing negative outcomes. Taken together, the results of the present studies showed (a) that it is possible to induce a placebo-nocebo effect on pain solely by a psychological manipulation, (b) that both, prior experiences and positive expectation, are necessary preconditions for this placebo-nocebo effect, (c) that the impact of negative emotion on pain can be dampened and even reversed by placebo-nocebo manipulations, and (d) that most likely a cognitive top-down process is crucial for the induction of (psychological) placebo-nocebo effects. These results significantly enhance our understanding of psychological mechanisms involved in the induction of placebo-nocebo effects. Further, a fruitful foundation for future studies is provided, which will need to determine the contributions of primarily nocebo or placebo responses mediating the effects as demonstrated in the present studies. In a long-term perspective, the present findings may also help to exploit placebo effects and prevent from nocebo effect in clinical contexts by further elucidating crucial psychological factors that contribute to the placebo and nocebo response.},
  subject      = {Placebo},
  language  = {en}
}