Merle, And so...if you had not had a dream, a plan of a zen garden, where would you be right now?
...Bill! --- In [email protected], Merle Lester <merlewiitpom@...> wrote: > > > >  bill... one may have a plan... this is a dream..i dreamt of my zen > garden... many moons ago..without the dream..the plan..it would not have > eventuate..merle >  > Merle, > > You asked: "if we did not have "dreams"... where would we be?". > > We would be right here, right now - exactly the same place we'd be if we did > have dreams. > > And yes, I have dreams - desires that the future will unfold in a certain way > that is beneficial to my self - but I don't (at least try not to) form > attachments to them. > > ...Bill! > > --- In [email protected], Merle Lester <merlewiitpom@> wrote: > > > > > > > > àbill...if we did not have "dreams"... where would we be?...surely you > > have "dreams" that come true...merle > > > > > > à> > Merle, > > > > Yes, dreams and predictions are delusions especially when they are > > perceived to have come true. > > > > And for the 437th time...only experience (sensual) is real IMO. > > > > ...Bill! > > > > --- In [email protected], Merle Lester <merlewiitpom@> wrote: > > > > > > > > > > > > Ãâàbill..so what about dreams and predictions ....?.... dreams and > > > predictions can come true ..." i had a dream"..martin luther king jr > > > Ãâàdo they fall in your notion of illusions and delusions? > > > Ãâàis anything real for you? > > > Ãâàmerle > > > Bill, > > > > > > > > > Yes, you are correct that my example does NOT establish anything external > > > to the space. > > > > > > However it is 100% self-evident that your view that I am a figment of > > > your imagination is 100% wrong. > > > > > > Why? Because here I am sitting here on the other side of the world > > > whether you or anyone else is alive or dead doing things you have no idea > > > whether I'm doing or not. > > > > > > So if anything it's YOU that is figment of MY imagination. > > > > > > So because we can both say this about the other it is clear that there is > > > an external reality common to both our experience, and it is clear that > > > external reality has a logical structure that accommodates both our > > > experiences... > > > > > > This is incontrovertible reality and thus it is Zen... > > > > > > Edgar > > > > > > On Jul 16, 2013, at 3:15 AM, Bill! wrote: > > > > > > > --J0Wn7g-Kgwnbh53pQHyl91Q8Xzhg-mgC2a929rM > > > > Content-Type: text/plain; charset=ISO-8859-1 > > > > Content-Transfer-Encoding: quoted-printable > > > > > > > > Edgar, > > > > > > > > I probably am much more proficient in math than you think, but I don't > > > > unde= > > > > rstand the relevance of your example below. > > > > > > > > For example I understand you can determine the shape of a space from > > > > inside= > > > > that space, but I fail to see how that could prove there is something > > > > outs= > > > > ide of that space. > > > > > > > > Can you? > > > > > > > > ...Bill! > > > > > > > > --- In [email protected], Edgar Owen <edgarowen@> wrote: > > > >> > > > >> Bill, > > > >> =20 > > > >> I understand what you are saying but you are wrong. For example it is > > > >> pos= > > > > sible to determine the shape of a space from inside that space by > > > > measuring= > > > > what the angles of triangles add up to. You don't have to be outside of > > > > yo= > > > > ur experience to understand there is something else outside it. I don't > > > > kno= > > > > w whether you know enough math for this to make sense to you. Maybe Joe > > > > or = > > > > Mike can explain it... > > > >> =20 > > > >> Edgar > > > >> =20 > > > >> =20 > > > >> =20 > > > >> On Jul 14, 2013, at 10:09 PM, Bill! wrote: > > > >> =20 > > > >>> Edgar, > > > >>> =20 > > > >>> I experience what I experience. You experience what you experience. > > > >>> Tha= > > > > t is the only reality that either of us have available to us. > > > >>> =20 > > > >>> All the rest that you claim to exist is speculation, > > > >>> intellectualizatio= > > > > ns; in other words delusions. > > > >>> =20 > > > >>> ...Bill! > > > >>> =20 > > > >>> --- In [email protected], Edgar Owen <edgarowen@> wrote: > > > >>>> > > > >>>> Bill, > > > >>>> =20 > > > >>>> Yes, you experience what you experience whatever. But it isn't > > > >>>> realit= > > > > y because it's different between observers... > > > >>>> =20 > > > >>>> There is an actual external reality that each observer experiences > > > >>>> it= > > > > differently... > > > >>>> =20 > > > >>>> But why O why am I wasting my time trying to teach you the obvious, > > > >>>> a= > > > > teaching that every Zen master from Buddha onward agrees with me on? > > > >>>> =20 > > > >>>> Edgar > > > >>>> =20 > > > >>>> =20 > > > >>>> =20 > > > >>>> On Jul 14, 2013, at 8:14 PM, Bill! wrote: > > > >>>> =20 > > > >>>>> Merle, > > > >>>>> =20 > > > >>>>> If you are color-blind or totally blind it makes no difference. You= > > > > experience what you experience. That which you experience is real. That > > > > wh= > > > > ich you perceive (think about, intellectualize) is not. > > > >>>>> =20 > > > >>>>> We do interpret our experiences with our mind. That's called percei= > > > > ving. And just as you say we interpret them to make sense out of them, > > > > but = > > > > it's WE, our human intellect, that 'makes the sense'. It's not as many > > > > beli= > > > > eve that our intellect 'discovers' the sense which is inherent in > > > > experienc= > > > > e. We create it and we superimpose it, force-fit it, onto our > > > > experience. > > > >>>>> =20 > > > >>>>> And yes, you're correct again that we perceive (apply our intellect= > > > > )in order to survive. That doesn't make our perceptions real, it only > > > > makes= > > > > them useful. > > > >>>>> =20 > > > >>>>> Our intellect does not make things real. Our intellect takes our ex= > > > > perience of reality and forces it into a little logical box so we can > > > > under= > > > > stand it. Our intellect distorts reality. That's called perception and > > > > is a= > > > > delusion (or illusion). > > > >>>>> =20 > > > >>>>> I'm not sure what you mean by 'and then there is a consensus' so I = > > > > cannot comment on that. > > > >>>>> =20 > > > >>>>> ...Bill! > > > >>>>> =20 > > > >>>>> --- In [email protected], Merle Lester <merlewiitpom@> wrot= > > > > e: > > > >>>>>> > > > >>>>>> =20 > > > >>>>>> =20 > > > >>>>>> =C2 so if one was colour blind...how would that fit into the sche= > > > > me of things? > > > >>>>>> ..it would not be the correct interpretation of the world..for in= > > > > stance traffic lights..=C2=20 > > > >>>>>> =20 > > > >>>>>> i do not believe one can totally trust our senses as being the on= > > > > ly real experience...what ever you mean by real...we see =C2 we hear we > > > > tou= > > > > ch we smell we taste...=C2=20 > > > >>>>>> =C2 one interpret this with our mind... > > > >>>>>> otherwise this world would make no sense what so ever...=C2=20 > > > >>>>>> =C2 one must in order to survive make meaning out of what we see,= > > > > hear, touch, smell and taste... > > > >>>>>> what other experiences are there apart from the sensory?...=C2=20 > > > >>>>>> i'd say they are the starting point not the all end to understand= > > > > ing the world... > > > >>>>>> we need our minds to make sense of the world surely?...and hence = > > > > an intellect... > > > >>>>>> =C2 then it becomes real real real... and one is able to communic= > > > > ate that reality to others > > > >>>>>> =C2 and then there is a consensus > > > >>>>>> =20 > > > >>>>>> merle > > > >>>>>> =20 > > > >>>>>> =C2=20 > > > >>>>>> Merle, > > > >>>>>> =20 > > > >>>>>> IMO only experience is real, and by that 'experience' I mean sens= > > > > ory experience (sight, sound, touch, smell, taste). > > > >>>>>> =20 > > > >>>>>> That's it. That's all. > > > >>>>>> =20 > > > >>>>>> ...Bill! > > > >>>>>> =20 > > > >>>>>> --- In [email protected], Merle Lester <merlewiitpom@> wr= > > > > ote: > > > >>>>>>> > > > >>>>>>> =20 > > > >>>>>>> =20 > > > >>>>>>> =C3=82=C2 bill..thank you for your clarification...so what is N= > > > > OT an illusion bill?...and what is real in your world?...merle > > > >>>>>>> =20 > > > >>>>>>> =20 > > > >>>>>>> =C3=82=C2=20 > > > >>>>>>> Merle, > > > >>>>>>> =20 > > > >>>>>>> Sure...as long as you tie it back to zen it's fair game as far = > > > > as I'm concerned. What this article is talking about is what Buddhism > > > > calls= > > > > 'suffering'. > > > >>>>>>> =20 > > > >>>>>>> Western medicine tries to alleviate it by prescribing medicatio= > > > > ns. > > > >>>>>>> =20 > > > >>>>>>> Most religions try to alleviate it by prescribing faith in God. > > > >>>>>>> =20 > > > >>>>>>> Art, music, work, activities of all sorts, etc.. help alleviate= > > > > it by having you concentrate on something else.=20 > > > >>>>>>> =20 > > > >>>>>>> Zen IMO tries to alleviate it by helping you experience these a= > > > > re delusive. > > > >>>>>>> =20 > > > >>>>>>> ...Bill!=20 > > > >>>>>>> =20 > > > >>>>>>> --- In [email protected], Merle Lester <merlewiitpom@> = > > > > wrote: > > > >>>>>>>> > > > >>>>>>>> =20 > > > >>>>>>>> =20 > > > >>>>>>>> =C3=83=E2=80=9A=C3=82=C2 i thought this was a good article as= > > > > to what bill talks about..illusions... hence zen appropriate..correct > > > > me i= > > > > f i am incorrect...bill... > > > >>>>>>>> merle > > > >>>>>>>>> > > > >>>>>>>>> > > > >>>>>>>>> > > > >>>>>>>>> > > > >>>>>>>>> Worried Sick > > > >>>>>>>>> Expectations can make you ill. Fear can make you fragile. Un= > > > > derstanding the nocebo effect may help prevent this painful phenomenon. > > > >>>>>>>>> By=C3=83=E2=80=9A=C3=82=C2 Megan Scudellari=C3=83=E2=80=9A= > > > > =C3=82=C2 |=C3=83=E2=80=9A=C3=82=C2 July 1, 2013 > > > >>>>>>>>> =C3=83=E2=80=9A=C3=82=C2=A9 BRYAN SATALINO > > > >>>>>>>>> Something strange was happening in New Zealand. In the fall = > > > > of 2007, pharmacies across the country had begun dispensing a new > > > > formulati= > > > > on of Eltroxin=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC"the only thyroid > > > > hormone re= > > > > placement drug approved and paid for by the government and used by tens > > > > of = > > > > thousands of New Zealanders since 1973. Within months, reports of side > > > > effe= > > > > cts began trickling in to the > > > > government=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC= > > > > =C3=A2=E2=80=9E=C2=A2s health-care monitoring agency. These included > > > > known = > > > > side effects of the drug, such as lethargy, joint pain, and depression, > > > > as = > > > > well as symptoms not normally associated with the drug or disease, > > > > includin= > > > > g eye pain, itching, and nausea. Then, the following summer, the > > > > floodgates= > > > > opened: in the 18 months following the release of the new tablets, the > > > > rat= > > > > e of Eltroxin adverse event reporting rose nearly 2,000-fold.1 > > > >>>>>>>>> The strange thing was, the active ingredient in the drug, th= > > > > yroxine, was exactly the same. Laboratory testing proved that the new > > > > formu= > > > > lation was bioequivalent to the old one. The only change was that the > > > > drugm= > > > > aker, GlaxoSmithKline, had moved its manufacturing process from Canada > > > > to G= > > > > ermany, and in the process altered the > > > > drug=C3=83=C2=A2=C3=A2=E2=80=9A=C2= > > > > =AC=C3=A2=E2=80=9E=C2=A2s inert qualities, including the > > > > tablets=C3=83=C2= > > > > =A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2 size, color, and markings. > > > >>>>>>>>> So why were people getting sick? In June, it turned out, new= > > > > spapers and TV stations around the country had begun to directly > > > > attribute = > > > > the reported adverse effects to the changes in the drug. Following > > > > widespre= > > > > ad coverage of the issue, more and more patients reported adverse > > > > events to= > > > > the government. And the areas of the country with the most intense > > > > media c= > > > > overage had the highest rates of reported ill effects, suggesting that > > > > perh= > > > > aps a little social persuasion was at play. > > > >>>>>>>>> =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"Nocebo=C3=83=C2=A2= > > > > =C3=A2=E2=80=9A=C2=AC (meaning > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"I sh= > > > > all harm=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC) is the dastardly sibling of > > > > plac= > > > > ebo (=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"I shall > > > > please=C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC). > > > >>>>>>>>> But Eltroxin takers were not making up their symptoms. The f= > > > > eelings were real, but in the vast majority of cases they could not be > > > > attr= > > > > ibuted to the > > > > drug=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s p= > > > > harmacological properties. The patients were victims of the nocebo > > > > effect. > > > >>>>>>>>> =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"Nocebo=C3=83=C2=A2= > > > > =C3=A2=E2=80=9A=C2=AC (meaning > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"I sh= > > > > all harm=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC) is the dastardly sibling of > > > > plac= > > > > ebo (=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"I shall > > > > please=C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC). In a placebo response, a sham medication or > > > > procedure = > > > > has a beneficial health effect as a result of a > > > > patient=C3=83=C2=A2=C3=A2= > > > > =E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s expectation. Sugar pills, for > > > > example= > > > > , can powerfully improve depression when the patient believes them to > > > > be an= > > > > tidepressants. But, researchers are learning, the reverse phenomenon is > > > > als= > > > > o common: negative expectations can actually cause harm. > > > >>>>>>>>> When Parkinson=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80= > > > > =9E=C2=A2s patients undergoing deep brain stimulation were told that > > > > their = > > > > brain pacemaker was going to be turned off, symptoms of their illness > > > > becam= > > > > e more pronounced, even when the pacemaker was left > > > > on.2=C3=83=E2=80=9A=C3= > > > > =82=C2 When people with and without lactose intolerance were asked to > > > > inges= > > > > t lactose, but were actually given glucose, 44 percent of those with > > > > lactos= > > > > e intolerance and 26 percent of those without it still complained of > > > > stomac= > > > > h pain.3=C3=83=E2=80=9A=C3=82=C2 And men treated for an enlarged > > > > prostate w= > > > > ith a commonly prescribed drug and told that the drug > > > > =C3=83=C2=A2=C3=A2=E2= > > > > =80=9A=C2=AC=C3=85"may cause erectile dysfunction, decreased libido, > > > > [and] = > > > > problems of ejaculation,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC but that > > > > these ef= > > > > fects were > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"uncommon,=C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC were more than twice as likely to experience > > > > impotence a= > > > > s those who were not so informed.4 > > > >>>>>>>>> On paper, it sounds like psychobabble=C3=83=C2=A2=C3=A2=E2= > > > > =80=9A=C2=AC"a negative effect caused by a sham treatment based on a > > > > patien= > > > > t=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s > > > > expectations=C3=83= > > > > =C2=A2=C3=A2=E2=80=9A=C2=AC"but it is a real biochemical and > > > > physiological = > > > > process, involving pain and stress pathways in the brain. And mounting > > > > evid= > > > > ence suggests that the nocebo effect is having a substantial negative > > > > impac= > > > > t on clinical research, medicine, and health. > > > >>>>>>>>> =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"Nocebo is at least a= > > > > s important as the placebo effect and may be more > > > > widespread,=C3=83=C2=A2= > > > > =C3=A2=E2=80=9A=C2=AC says Ted Kaptchuk, director of > > > > Harvard=C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s Program in Placebo Studies at > > > > Beth= > > > > Israel Deaconess Medical Center in Boston, Massachusetts. > > > >>>>>>>>> Now that this pernicious phenomenon is starting to receive t= > > > > he recognition it deserves, the question is: What exactly can be done > > > > about= > > > > it? > > > >>>>>>>>> Evil effects > > > >>>>>>>>> ALLERGIC TO NOCEBO > > > >>>>>>>>> =C3=83=E2=80=9A=C3=82=C2=A9 BRYAN SATALINO > > > >>>>>>>>> According to several recent studies, pain and itch appear to= > > > > be especially susceptible to verbal suggestion. Recently, researchers > > > > in t= > > > > he Netherlands demonstrated that people who are told that a stimulus > > > > will c= > > > > ause itch feel the itch more intensely than those told that the > > > > stimulus is= > > > > unlikely to cause itch. The finding could have implications for chronic > > > > it= > > > > ch conditions, says first author Antoinette van Laarhoven of Radboud > > > > Univer= > > > > sity Nijmegen Medical Center. > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"More = > > > > knowledge about nocebo effects on itch can give us some targets to > > > > reduce [= > > > > those effects].=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC > > > >>>>>>>>> Also last year, in a curious study of nocebo and rectal pain= > > > > , a team at University Hospital Essen in Germany managed to recruit > > > > healthy= > > > > volunteers to undergo multiple rectal balloon distensions, a procedure > > > > in = > > > > which a balloon is inserted into the rectum and slowly > > > > inflated=C3=83=C2=A2= > > > > =C3=A2=E2=80=9A=C2=AC"in this case, until the moment it becomes > > > > painful. Th= > > > > e procedures were exactly the same in control and nocebo groups, but > > > > there = > > > > was a 20 percent increase in pain ratings among patients who had been > > > > told = > > > > that doctors had observed an increase in pain sensitivity in response > > > > to re= > > > > peated distensions. Those individuals who experienced more pain also > > > > had el= > > > > evated levels of cortisol, again linking nocebo to anxiety. > > > > =C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC=C3=85"We could show that a nocebo effect may be > > > > induced = > > > > even by mere information,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says Sven > > > > Benson= > > > > , an author on the paper. > > > >>>>>>>>> Another area of health that researchers suspect may be affec= > > > > ted by nocebo is the increased incidence of asthma and allergies. > > > > =C3=83=C2= > > > > =A2=C3=A2=E2=80=9A=C2=AC=C3=85"It=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2= > > > > =80=9E=C2=A2s certainly possible,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says > > > > Man= > > > > fred Schedlowski, who studies placebo and the immune system at > > > > University H= > > > > ospital Essen. =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"From > > > > experimental da= > > > > ta, we know an allergic reaction can be > > > > conditioned.=C3=83=C2=A2=C3=A2=E2= > > > > =80=9A=C2=AC > > > >>>>>>>>> In an oft-cited case from 1886, John Mackenzie, a surgeon in= > > > > Baltimore, described how > > > > he=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80= > > > > =9E=C2=A2d =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"obtained an > > > > artificial r= > > > > ose of such exquisite workmanship that it presented a perfect > > > > counterfeit o= > > > > f the original,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC then exposed a woman > > > > with = > > > > severe rose allergy to the fake flower. The woman, not knowing it was > > > > fake,= > > > > had a full-blown allergic reaction, including a running nose, swollen > > > > nost= > > > > rils, and a tight chest.12 Similarly, people allergic to dogs may begin > > > > sne= > > > > ezing when they simply see a dog across the way. Researchers have even > > > > show= > > > > n that guinea pigs can be conditioned to release histamine, causing a > > > > local= > > > > immune response, when presented with just an odor stimulus. > > > >>>>>>>>> But the link between nocebo and allergy is far from concrete= > > > > . > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"We=C3=83=C2=A2=C3=A2=E2=80=9A=C2= > > > > =AC=C3=A2=E2=80=9E=C2=A2re in such a primitive state of understanding > > > > this = > > > > phenomenon, particularly in a clinically oriented way, that we just > > > > need to= > > > > do more research,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says bioethicist > > > > Frank = > > > > Miller of the National Institutes of Health.=20 > > > >>>>>>>>> In 1997, Fabrizio Benedetti, a neurophysiologist at the Univ= > > > > ersity of Turin Medical School in Italy, was busy mapping the > > > > biochemical p= > > > > athways involved in placebo responses when he performed a simple study > > > > that= > > > > revealed a distinct neural mechanism driving the > > > > body=C3=83=C2=A2=C3=A2=E2= > > > > =80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s nocebo response. He gave consenting > > > > post= > > > > operative patients reporting mild pain an injection that they were told > > > > wou= > > > > ld increase their pain within 30 minutes. The injection was either > > > > saline s= > > > > olution or proglumide, which blocks a hormone implicated in pain > > > > hypersensi= > > > > tivity and associated with anxiety. Neither substance actually causes > > > > any d= > > > > iscomfort. > > > >>>>>>>>> When saline was injected, patients experienced increased pai= > > > > n. When proglumide was injected, they had no pain > > > > increase=C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC"the nocebo effect was > > > > absent.5=C3=83=E2=80=9A=C3=82=C2 I= > > > > n one fell swoop, Benedetti identified a biochemical reaction > > > > responsible f= > > > > or the nocebo response, and he showed that it could be blocked. > > > >>>>>>>>> It was Benedetti=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2= > > > > =80=9E=C2=A2s work that finally convinced physician-bioethicist Howard > > > > Brod= > > > > y that the nocebo effect=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC"allegedly > > > > first m= > > > > entioned in the scientific literature in 1961 by physician Walter > > > > Kennedy, = > > > > who called the phenomenon a > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"quality= > > > > inherent in the patient rather than in the > > > > remedy=C3=83=C2=A2=C3=A2=E2=80= > > > > =9A=C2=AC=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC"was real. > > > >>>>>>>>> =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"For many years, I di= > > > > smissed the value of the term > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=8B=C5"no= > > > > cebo,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2=C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC=C3=A2=E2=82=AC=C2=B0=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC > > > > sa= > > > > ys Brody, chair of family medicine and director of the Institute for > > > > the Me= > > > > dical Humanities at the University of Texas Medical Branch in > > > > Galveston, wh= > > > > o first began studying the placebo effect in the 1970s. He and others > > > > had l= > > > > ong assumed that nocebo and placebo were two sides of one coin, that > > > > the sa= > > > > me process in the brain supported both illusory > > > > effects=C3=83=C2=A2=C3=A2= > > > > =E2=80=9A=C2=AC"one was just manifested as a positive outcome, while > > > > the ot= > > > > her caused harm. But after reading > > > > Benedetti=C3=83=C2=A2=C3=A2=E2=80=9A=C2= > > > > =AC=C3=A2=E2=80=9E=C2=A2s work, Brody changed his tune: > > > > =C3=83=C2=A2=C3=A2= > > > > =E2=80=9A=C2=AC=C3=85"I received my > > > > comeuppance,=C3=83=C2=A2=C3=A2=E2=80=9A= > > > > =C2=AC he laughs. > > > >>>>>>>>> With that first biochemical evidence, others also began reco= > > > > gnizing the importance of nocebo, and a few inquiring minds began to > > > > study = > > > > it. Nevertheless, compared to placebo, the nocebo effect remains vastly > > > > und= > > > > erstudied: a PubMed database search will turn up more than 163,000 > > > > publicat= > > > > ions on > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"placebo=C3=83=C2=A2=C3=A2= > > > > =E2=80=9A=C2=AC and fewer than 200 on > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3= > > > > =85"nocebo.=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC Of those, only a few dozen > > > > are= > > > > empirical studies; most are reviews. > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3= > > > > =85"The placebo phenomenon has a tremendous fascination for the > > > > public=C3= > > > > =83=C2=A2=C3=A2=E2=80=9A=C2=AC"a gee-whiz thing with a positive spin, a > > > > way= > > > > to be healthy without taking drugs,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC > > > > says = > > > > Frank Miller, a bioethicist at the National Institutes of Health. > > > > =C3=83=C2= > > > > =A2=C3=A2=E2=80=9A=C2=AC=C3=85"But nobody is very enthusiastic about > > > > the no= > > > > cebo phenomenon.=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC > > > >>>>>>>>> In addition, the nocebo effect has become notoriously diffic= > > > > ult to study. Few institutional review boards will allow scientists to > > > > indu= > > > > ce pain in their subjects, and some even refuse to let researchers > > > > mislead = > > > > their volunteers. =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"My ethics > > > > committ= > > > > ee will not allow me to do it,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says > > > > Paul E= > > > > nck, a psychologist at the University of T=C3=83=C6'=C3=82=C2=BCbingen > > > > in G= > > > > ermany, =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"unless I tell the > > > > subjects = > > > > that I am deceiving > > > > them=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=83=C2=A2=C3=A2= > > > > =E2=80=9A=C2=AC"a requirement that obviously defeats the purpose of the > > > > dec= > > > > eption. =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"It makes life really > > > > misera= > > > > ble as a [nocebo] researcher,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says > > > > Enck. > > > >>>>>>>>> The tragedy of this lack of investigation, researchers asser= > > > > t, is that controlled trials about the nocebo effect are needed to > > > > further = > > > > understand and prevent > > > > nocebo=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80= > > > > =9E=C2=A2s insidious effects on medicine and research. > > > > =C3=83=C2=A2=C3=A2= > > > > =E2=80=9A=C2=AC=C3=85"In clinical drug trials, the placebo > > > > effect=C3=83=C2= > > > > =A2=C3=A2=E2=80=9A=C2=AC"and now we know the nocebo > > > > effect=C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC"can be really, really > > > > large,=C3=83=C2=A2=C3=A2=E2=80=9A= > > > > =C2=AC says Manfred Schedlowski, a clinical researcher at the > > > > University Ho= > > > > spital Essen in Germany. =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"This > > > > hinde= > > > > rs the development of new drugs.=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC > > > >>>>>>>>> In December 2012, for example, a meta-analysis revealed the = > > > > shockingly large impact of the nocebo effect in clinical trials: in 18 > > > > fibr= > > > > omyalgia drug studies, 11 percent of 3,546 patients in the placebo > > > > arm=C3= > > > > =83=C2=A2=C3=A2=E2=80=9A=C2=AC"meaning they were receiving a completely > > > > ine= > > > > rt substance=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC"dropped out of the study > > > > beca= > > > > use of side effects including dizziness and > > > > nausea.6=C3=83=E2=80=9A=C3=82= > > > > =C2 Other studies have calculated that nocebo effects cause between 4 > > > > and 2= > > > > 6 percent of patients taking placebo to leave a clinical trial because > > > > of s= > > > > ide effects from an inert treatment. > > > >>>>>>>>> The nocebo effect may also have a worrisome effect on vaccin= > > > > e use. In 2011, researchers at the French vaccine manufacturer Sanofi > > > > Paste= > > > > ur analyzed 33,275 vaccine side-effect reports and found that doctors > > > > and p= > > > > atients preferentially report disease-specific side effects, such as > > > > measle= > > > > s-like rash following measles immunization, even when the vaccine > > > > contains = > > > > only proteins, sugars, or killed organisms that > > > > won=C3=83=C2=A2=C3=A2=E2=80= > > > > =9A=C2=AC=C3=A2=E2=80=9E=C2=A2t cause symptoms of the disease. The > > > > nocebo e= > > > > ffect has =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"great > > > > potential=C3=83=C2= > > > > =A2=C3=A2=E2=80=9A=C2=AC to exacerbate rumors and fears, and to cause a > > > > vac= > > > > cine crisis similar to the Eltroxin events in New Zealand, the authors > > > > writ= > > > > e.7 > > > >>>>>>>>> But the most common place where the nocebo effect makes an a= > > > > ppearance is in everyday visits to clinics and hospitals. > > > > =C3=83=C2=A2=C3= > > > > =A2=E2=80=9A=C2=AC=C3=85"In places like primary care, people are > > > > swimming i= > > > > n placebo and nocebo effects,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says > > > > Kaptchu= > > > > k. > > > >>>>>>>>> Thomas D=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2= > > > > =A2Amico, chief of thoracic surgery at Duke University Medical Center > > > > in Du= > > > > rham, North Carolina, says that even before he heard the term nocebo > > > > effect= > > > > , he was aware of it in the clinic. > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85= > > > > "I=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2ve listened to > > > > some= > > > > well-respected colleagues give information [to a patient], and I > > > > thought, = > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=8B=C5"Gosh, I know the operation > > > > and e= > > > > ven I wouldn=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2t > > > > want it= > > > > ,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2=C3=83=C2=A2=C3=A2= > > > > =E2=80=9A=C2=AC he says. > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"There=C3= > > > > =83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s too much detail > > > > and to= > > > > o much emphasis about things that could go > > > > wrong.=C3=83=C2=A2=C3=A2=E2=80= > > > > =9A=C2=AC Measuring the effect of such detail on an individual patient > > > > is h= > > > > ard to quantify, he says, but fear and distress before an operation has > > > > bee= > > > > n associated with slow postoperative recovery and delayed wound healing. > > > >>>>>>>>> Nuts and bolts > > > >>>>>>>>> =C3=83=E2=80=9A=C3=82=C2=A9 BRYAN SATALINODespite the dispro= > > > > portionate amount of effort put into placebo research, since > > > > Benedetti=C3= > > > > =83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s 1997 discovery > > > > there= > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s been an uptick > > > > in t= > > > > he funding and time devoted to investigating the mechanisms behind > > > > nocebo, = > > > > with impressive results. > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"Without a = > > > > doubt, there=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s > > > > been a = > > > > level of research and a sophistication of research that has made a > > > > quantum = > > > > jump in the last decade or so,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says > > > > Brody. > > > >>>>>>>>> In 2007, for example, Benedetti discovered that the hypothal= > > > > amic-pituitary-adrenal axis in the brain, an important part of the > > > > body=C3= > > > > =83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2s > > > > =C3=83=C2=A2=C3=A2=E2= > > > > =80=9A=C2=AC=C3=85"stress system,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC is > > > > activ= > > > > ated during a nocebo response, as detected by an increase in the > > > > secretion = > > > > of the hormones ACTH, from the pituitary gland, and cortisol, from the > > > > adre= > > > > nal gland, both markers of anxiety.8 > > > >>>>>>>>> Then, in 2008, Kaptchuk and colleagues at Harvard performed = > > > > the first brain-imaging study of the nocebo effect. After conditioning > > > > heal= > > > > thy volunteers to expect pain on their right forearm, they watched as > > > > the h= > > > > ippocampus lit up when people experienced pain from a sham acupuncture > > > > devi= > > > > ce. > > > >>>>>>>>> Through Benedetti=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2= > > > > =80=9E=C2=A2s and > > > > Kaptchuk=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E= > > > > =C2=A2s work, it is now clear that a > > > > person=C3=83=C2=A2=C3=A2=E2=80=9A=C2= > > > > =AC=C3=A2=E2=80=9E=C2=A2s expectation of pain can induce anticipatory > > > > anxie= > > > > ty, triggering the activation of cholecystokinin, the hormone that > > > > Benedett= > > > > i blocked with proglumide. Cholecystokinin-mediated pathways in turn > > > > facili= > > > > tate pain transmission, which occurs in specific areas of the brain. > > > > The fi= > > > > nding does not coincide with what is know about the biochemistry of the > > > > pla= > > > > cebo effect=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC"which seems to be at least > > > > par= > > > > tly regulated by opioid > > > > release=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC"suggesting= > > > > the two phenomena have distinct mechanisms. > > > >>>>>>>>> =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"Even if placebo and = > > > > nocebo are on a continuum of expectation, different mechanisms kick in > > > > at d= > > > > ifferent points along that continuum,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC > > > > says= > > > > Tor Wager, director of the Cognitive and Affective Control Laboratory > > > > at t= > > > > he University of Colorado, Boulder, who studies the brain pathways > > > > underlyi= > > > > ng pain. > > > >>>>>>>>> Last year, Kaptchuk and colleagues added a surprising twist = > > > > when they discovered nocebo can occur without conscious awareness. His > > > > team= > > > > applied either high or low heat pain to the arms of 20 volunteers while > > > > sh= > > > > owing them an image of one of two faces. The researchers then showed > > > > the vo= > > > > lunteers the faces again, but with identical, moderate heat applied to > > > > thei= > > > > r arms each time and the faces displayed at a much faster pace, > > > > preventing = > > > > conscious recognition. When exposed to the faces associated with high > > > > pain = > > > > levels, even without conscious awareness, the volunteers felt more > > > > pain.9= > > > > =C3=83=E2=80=9A=C3=82=C2 =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"It was > > > > a r= > > > > eally risky experiment,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says Kaptchuk. > > > > =C3= > > > > =83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"We were really surprised. We > > > > couldn=C3= > > > > =83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2t believe it, > > > > actually.= > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC > > > >>>>>>>>> The biochemical and physiological discoveries about nocebo h= > > > > ave made the phenomenon more credible in the medical community. > > > > =C3=83=C2= > > > > =A2=C3=A2=E2=80=9A=C2=AC=C3=85"These brain measures provide objective > > > > evide= > > > > nce on the physical system implementing these squishy, fuzzy changes in > > > > emo= > > > > tion and expectation,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC says Wager. > > > >>>>>>>>> Most nocebo research to date, however, focuses on basic mech= > > > > anisms, not on how to deal with the phenomenon in the clinic. > > > > =C3=83=C2=A2= > > > > =C3=A2=E2=80=9A=C2=AC=C3=85"Translational research has been a stepchild > > > > in = > > > > scientific investigations of this > > > > phenomenon,=C3=83=C2=A2=C3=A2=E2=80=9A=C2= > > > > =AC says Miller. Understanding the mechanism is important, but at the > > > > end o= > > > > f the day, he says, the medical community needs a solution to the > > > > problem. > > > >>>>>>>>> Controlling for nocebo > > > >>>>>>>>> In 1987, a team of doctors in Ontario, Canada, suspected tha= > > > > t medical consent forms might actually cause harm. Using the chance > > > > occurre= > > > > nce of two different consent forms being used for the same drug trial, > > > > they= > > > > compared patient reactions to the wording of the forms. The trial > > > > pitted a= > > > > spirin against sulfinpyrazone, a medicine already approved to treat > > > > gout, a= > > > > s a treatment for chest pain. Patients at two of the three centers > > > > hosting = > > > > the trial were informed that > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=85"side e= > > > > ffects are not anticipated beyond occasional gastrointestinal > > > > irritation an= > > > > d, rarely, skin rash.=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC At the third > > > > center,= > > > > patients=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3=A2=E2=80=9E=C2=A2 consent > > > > for= > > > > ms did not mention gastrointestinal effects. Seventy-six patients out > > > > of 39= > > > > 9 (19 percent) given the first consent form that mentioned GI > > > > irritation wi= > > > > thdrew from the study, citing GI issues, compared to just 5 out of 156 > > > > (3 p= > > > > ercent) who received the second form.10 > > > >>>>>>>>> With the nocebo effect, doctors are caught between a rock an= > > > > d a hard place: their medical duty to primum non nocere, > > > > =C3=83=C2=A2=C3=A2= > > > > =E2=80=9A=C2=AC=C3=85"First, do no > > > > harm,=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC a= > > > > nd the ethical and regulatory obligation of informed consent. What do > > > > you d= > > > > o when informed consent leads to harm? > > > >>>>>>>>> Last year, Kaptchuk and colleague Rebecca Wells, also at Har= > > > > vard Medical School, sparked a debate on this topic in the pages of > > > > the=C3= > > > > =83=E2=80=9A=C3=82=C2 American Journal of Bioethics. They proposed a > > > > middle= > > > > ground called contextualized informed consent. Doctors, they suggested, > > > > mi= > > > > ght choose not to tell patients every last side effect of a treatment > > > > in gr= > > > > eat detail, but instead provide information to a patient tailored to > > > > his or= > > > > her level of anxiety, such as leaving out nonspecific side > > > > effects=C3=83= > > > > =C2=A2=C3=A2=E2=80=9A=C2=AC"those that are not a direct result of the > > > > pharm= > > > > acological action of the > > > > drug=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC"including he= > > > > adache, nausea, and fatigue. > > > >>>>>>>>> Nocebo is at least as important as the placebo effect and ma= > > > > y be more > > > > widespread.=C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC"=C3=83=E2=80=9A=C3= > > > > =82=C2=AD Ted Kaptchuk, Program in Placebo Studies, > > > >>>>>>>>>> Beth Israel Deaconess Medical Center, Harvard University > > > >>>>>>>>> But the idea of not informing patients of all possible side = > > > > effects is anathema to some ethicists. > > > > =C3=83=C2=A2=C3=A2=E2=80=9A=C2=AC=C3= > > > > =85"I c > > > > > > ------------------------------------ Current Book Discussion: any Zen book that you recently have read or are reading! 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