Cognitive Psychotherapy and the Placebo Effect

Yiannis G Papakostas, George Christodoulou
European Psychiatric Review, 2010;3(1):13-15
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Abstract

There are two major issues pertaining to the relationship of cognitive therapy and the placebo effect: efficacy and mechanism of action. Efficacy refers to the fact that the placebo effect is a potentially therapeutic ingredient in every healing situation, including cognitive psychotherapy. Mechanism of action refers to the hypothesis that conditioning and expectations are major explanatory constructs for both cognitive therapy and placebo. In this article we briefly discuss the efficacy and mechanisms of action of cognitive therapy and their association with the placebo effect. We conclude that the effects of both cognitive therapy and common factors (including the placebo effect) exceed those of nontreatment, while the effect of cognitive therapy surpasses that of common factors. Data, especially from advanced new technologies, reveal that both modalities modify neuronal function and structure, possibly in a partially different manner.
Keywords
Cognitive therapy, placebo effect, efficacy, mechanism of action, conditioning, expectation, neuroimaging
Disclosure The authors have no conflicts of interest to declare.
Received: December 02, 2009 Accepted February 23, 2010
Correspondence: Yiannis G Papakostas, Eginition Hospital, Vas Sophias Av 72, Athens, Greece. E: Yiargeke@hol.gr

There are at least two major areas in which cognitive therapy (CT) and the placebo effect overlap: efficacy and mechanism(s) of action. First, cognitive psychotherapy, like any therapy or healing situation, has three major potentially healing ingredients: the time effect or physical course of the illness (vis medicatrix naturae), the specific effect by which a therapy exerts its theory-driven effect and the placebo effect.1–3 Second, in both situations – CT and placebo – conditioning and expectations are believed to be important in mediating their presumed action.4,5

We will briefly compare the efficacy and mechanism of action of CT with those of placebo. However, two major conceptual issues impeding evaluations are worth noting. First, as opposed to pharmacotherapy research, where a pharmacological placebo arm in randomised controlled trials (RCTs) is feasible, in psychological therapies a psychological ‘placebo arm’ (‘sham, fake, false, inert or empty’) is problematic or even impossible6 and blindness is not guaranteed.7 Second, CT and placebo are both ‘top-down’ interventions initiated in the frontal cortical areas,8 the dorsolateral prefrontal cortex being considered as the entry point for verbal psychotherapies.9 It is therefore conceivable that both efficacy and mechanisms are much harder to study than medication effect, which is characterised by a bottom-up intervention with specific healing ingredients, whether physiological or pharmacological in nature.

The Efficacy Issue (Outcome Research)

CT in the form of cognitive behaviour therapy (CBT) is considered to be the best-known and best-tested psychological intervention in the clinical field, with many indications.10,11

Several reviews and meta-reviews show that CT is an effective treatment for various disorders. Its overall empirical status was studied in a review of 16 meta-analyses by Butler et al.,12 who concluded that the existing data support the efficacy of CBT: large effect sizes were found in unipolar depression, in most of the adult anxiety disorders and in childhood depression and anxiety disorders, while its effect on marital distress, anger, childhood somatic disorders and chronic pain is in the moderate range and even smaller for sexual offenders.

References:
  1. Brody H, Placebo effect: an examination of Grunbaum’s definition. In: White L, Tursky B, Schwartz G, eds., Placebo: Theory, Research, and Mechanisms, New York: Guilford Press, 1985;37–58.
  2. Ernst E, Resch KL, Concept of true and perceived placebo effects, Br Med J, 1995;311:551–3.
  3. Papakostas YG, Daras MD, Placebo, placebo effect, and the response to the healing situation: the evolution of a concept, Epilepsia, 2001;42:1614–25.
  4. Kirsch I, Ther placebo effect and the cognitive– behavioral revolution, Cogn Ther Res, 1978;2(3):255–64.
  5. Stewart-Williams S, Podd J, The placebo effect: dissolving the expectancy versus conditioning debate, Psychol Bull, 2004;130:324–40.
  6. Kirsch I, Placebo psychotherapy: synonym or oxymoron?, J Clin Psychology, 2005;61(7):791–803.
  7. Hofmann SG, Smits JAJ, Cognitive–behavioral therapy for adult anxiety disorders: a meta-nalysis of randomized placebo controlled trials, J Clin Psychiatry, 2008;69:621–32.
  8. Faria V, Fredrikson M, Furmark T, Imaging the placebo response: a neurofunctional review, Eur Neuropsychopharmacol, 2008;18:473–85.
  9. Viamontes GI, Beitman BD, Neural substrates of psychotherapeutic change. Part II: Beyond default mode, Psychiatric Annals, 2006;36(4):238–46.
  10. Enright SJ, Cognitive behavior therapy – clinical applications, Br Med J, 1997;314:1811–16.
  11. Beck AT, The current status of cognitive therapy. A 40-year retrospective, Arch Gen Psychiatry, 2005;62:953–9.
  12. Butler AC, Chapman JE, Forman EM, et al., The empirical status of cognitive-behavioral therapy: a review of metanalysis, Clin Psychol Rev, 2006;26:17–31.
  13. DeRubeis RJ, Siegle GJ, Hollon SD, Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms, Nat Rev Neurosci, 2008;9:(10): 788–96.
  14. Miklowitz DJ, Adjunctive psychotherapy for bipolar disorder, Am J Psychiatry, 2008;165:1408–19.
  15. Summathipala A, What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies, Psychosom Med, 2007;69(9):889–900.
  16. Walsh BT, Seidman SN, Sysko R, et al., Placebo response in studies of major depression. Variable, substantial, and growing, JAMA, 2002;287:1840–47.
  17. Sysko R, Walsh BT, A systematic review of placebo response in studies of bipolar mania, J Clin Psychiatry, 2007;68(8):1213–17.
  18. Khan A, Kolts RL, Rapaport MH, et al., Magnitude of placebo response and drug – placebo differences across psychiatric disorders, Psychol Med, 2005;35:743–9.
  19. Meissner K, Distel H, Mitzdorf U, Evidence for placebo effects on physical but not on biochemical outcome parameters: a review of clinical trials, BMC Med, 2007;5:3.
  20. Papakostas GI, Perlis RH, Scalla MJ, et al., A metaanalysis of early sustained response rates between antidepressants and placebo for the treatment of major depressive disorder, J Clin Psychopharmacol, 2006;26:56–60.
  21. Khan A, Redding N, Brown WA, The persistence of the placebo response in antidepressant clinical trials, J Psychiatric Research, 2008;42:791–6.
  22. Frank JD, The therapeutic factors in psychotherapy, Am J Psychotherapy, 1971;25:350–61.
  23. Luborsky L, Rosenthal R, Diguer L, et al., The Dodo bird verdict is alive and well – mostly, Clin Psychol Sci Pract, 2002;9:2–12.
  24. Cuijpers P, van Straten A, Andersson G, et al., Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies, J Consult Clin Psychol, 2008;76:909–22.
  25. DeRubeis RJ, Brotman MA, Gibbons CJ, A conceptual and methodological analysis of the nonspecific argument, Clin Psychol Sci Pract, 2005;12;174–83.
  26. Beutler LE, The Dodo bird is extinct, Clin Psychol Sci Prac, 2002;9:30–34.
  27. Thase ME, Friedman ES, Berman SR, et al., Is cognitive behavior therapy just a ‘nonspecific’ intervention for depression? A retrospective comparison of consecutive cohorts treated with cognitive behavior therapy or supportive counseling and pill placebo, J Affect Disord, 2000;57:63–71.
  28. Murphy R, Cooper Z, Hollon SD, et al., How do psychological treatments work? Investigating mediators of change, Behav Ther Res, 2009;47:1–5.
  29. DeRebeis RJ, Evans MD, Hollon SM, et al., How does cognitive therapy work-cognitive change and symptom change in cognitive therapy and pharmacotherapy for depression, J Consult Clin Psychol, 1990;58(6):862–9.
  30. Quilty LC, McBride C, Bagby RM, Evidence for the cognitive mediational model of cognitive behavioural therapy for depression, Psychol Med, 2008;38:1531–41.
  31. Hofmann SG, Cognitive mediation of treatment change in social phobia, J Consult Clin Psychol, 2004;72:392–9.
  32. Hofmann SG, Suvak MK, Barlow DH, et al., Preliminary evidence for cognitive mediation during cognitive– behavioral therapy of panic disorder, J Consult Clin Psychology, 2007;73(3):374–9.
  33. Turner J, JA, Holtzman S, Lloyd M, Mediators, moderators and predictors of therapeutic change in cognitive– behavioral therapy for chronic pain, Pain, 2007;127:278–86.
  34. Garratt G, Ingram RE, Cognitive processes in cognitive therapy: evaluation of mechanisms of change in the treatment of depression, Clin Psychol Sci Prac, 2007;14: 224–39.
  35. Beck AT, The evolution of the cognitive model of depression and its neurobiological correlates, Am J Psychiatry, 2008;165:969–77.
  36. Rot AH, Mathew SJ, Charney DS, Neurobiological mechanisms in major depression, CMAJ, 2009;180: 305–13.
  37. Linden DEJ, How psychotherapy changes the brain – the contribution of functional neuroimaging, Mol Psychiatry, 2006;11:528–38.
  38. Beauregard M, Mind does really matter: evidence from neuroimaging studies of emotional self-regulation, psychotherapy and placebo effect, Prog Neurobiol, 2007;81:218–36.
  39. Frewen PA, Dozois DJA, Lanius RA, Neuroimaging studies of psychological interventions for mood and anxiety disorders, Clin Psychol Rev, 2008;28:228–46.
  40. Schwartz JM, Stoessel PW, Baxter LR Jr, et al., Systematic changes in cerebral glucose metabolic rate after successful behavior modification treatment of obsessive–compulsive disorder, Arch Gen Psychitary, 1996;53(2):109–13.
  41. Saxena S, Gorbis E, O’Neil J, et al., Rapid effects of brief intensive cognitive–behavioral therapy on brain metabolism in obsessive–compulsive disorder, Mol Psychiatry, 2009;14:197–205.
  42. Furmark T, Tillfords M, Merteindottir I, et al., Common changes in cerebral flow in patients with social phobia treated with citalopram or cognitive–behavioral therapy, Arch Gen Psychiatry, 2002;59:425–33.
  43. Schienle A, Schafer A, Hermann A, et al., Symptom provocation and reduction in patients suffering from spider phobia, Eur Arch Psychiatry Clin Neurosci, 2007;257: 486–93.
  44. Paquette V, Levesque J, Mensour B, et al., “Change the mind and you change the brain”: effects of cognitive– behavioral therapy on the neural therapy on the neural correlates of spider phobia, Neuro Image, 2003;18:401–9.
  45. Straube T, Glauer M, Dilger S, et al., Effects of cognitive– behavioral therapy on brain activation in specific phobia, Neuro Image, 2006;29:125–35.
  46. Benedetti F, Pollo A, Lopiano L, et al., Conscious expectation, and unconscious conditioning in analgesic motor and hormonal placebo/nocebo responses, J Neuroscience, 2003;23(10):4315.
  47. de la Fuente-Fernandez R, Ruth TJ, Sossi V, et al., Expectation and dopamine release: mechanism of placebo effect in Parkinson’ disease, Science, 2001;293: 1164–6.
  48. Beneddeti F, Mayberg HS, Wager TD, et al., Neurological mechanisms of the placebo effect, J Neurosci, 2005;25(45): 10390–402.
  49. Lindstone SC, Stoessl AJ, Understanding the placebo effect: contributions from neuroimaging, Mol Imaging Biol, 2007;9:16–185.
  50. Diederich NJ, Goetz CG, The placebo treatments in neurosciences, Neurology, 2008;71:677–84.
  51. Mayberg HS, Silva JA, Brannan SK, et al., The functional neuroanatomy of the placebo effect, Am J Psychiatry, 2002;159:728–37.
  52. Mayberg HS, Defining neurocircuits in depression, Psychiatric Ann, 2006;36(4):259–68.
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