Health Exam

Placebo vs Nocebo

Placebo: A physical or psychological improvement after receiving an inert treatment (no effect, sugar pill, saline injection).

Nocebo: Undesirable side effects, increased pain or worsening symptoms experienced after receiving an inert treatment.

Placebo Analgesia vs Nocebo hyperalgesic

P: Pain relief caused by a patient’s belief or expectation that they are receiving an active medical treatment.

N: A person feels more pain simply because they expect or are told that it will hurt, even if they are given something harmless, like a fake pill or a mock procedure.

The authors (Aslaksen, P. M., & Lyby, P. S.) suggest that there are ethical constraints around investigations of the nocebo effect. What exactly are those ethical considerations/constraints?

Negative expectations can cause real physical or psychological harm, which raises ethical challenges because researchers and clinicians must intentionally or inadvertently induce discomfort, pain or anxiety.

Give two reasons why the authors (Aslaksen, P. M., & Lyby, P. S.) think it is reasonable to assume that the personality trait ‘neuroticism’ will affect the nocebo response.

1 . Neuroticism is the tendency to experience negative emotions and cognitions. Negative emotions increase pain; therefore, it is reasonable to expect that individuals with high neuroticism are more prone to be affected by suggestions of pain increase compared to lower neuroticism.

 

2. Neuroticism is linked to reduced placebo analgesia (pain relief caused by a patient’s belief or expectation that they are receiving an active medical treatment).

(Aslaksen, P. M., & Lyby, P. S.) Can you explain how pain was administered? What is a thermode, and did the temperature change from the baseline temp (32 degrees)?

Heat (aluminum contact thermode, lasting 20s, with a plateau of about 16 seconds at 47°C.
A thermode is a contact device that delivers controlled heat to the skin.

Yes, the thermode had a baseline temp of 32°C when applied to the arm and rose to 47°C, held there for about 16s and returned towards baseline.

(Aslaksen, P. M., & Lyby, P. S.) How was pain measured?

Computerised visual analog scale (COVAS) from ‘no pain’ to 100 ‘the most intense pain imaginable ’, and the mean of that continuous rating was used as the pain score for the trial.

(Aslaksen, P. M., & Lyby, P. S.) What was the mean pain rating at Post Test 1 for the nocebo group and the natural history group? Why does this demonstrate a nocebo effect?

Mean Nocebo Group Pain Rating = 60.20

 

Mean Natural History Group Pain Rating = 48.37

 

This is a clear nocebo effect because the groups did not differ at pretest, but after the inert cream was paired with suggestions of increased pain, the nocebo group reported significantly higher pain.

(Aslaksen, P. M., & Lyby, P. S.) What was the only personality variable to correlate with the pain change score pre-post (in both groups)? + What is BFI-10?

Fear of medical pain. None of the five BFI-10 personality factors (including neuroticism) correlated with the change in pain.

Big-Five Inventory-10 measures the five-factor model of personality
Openness
Conscientiousness
Extraveresion
Agreeableness
Neuroticism

(Aslaksen, P. M., & Lyby, P. S.) What was the specific hypothesis around neuroticism that was not supported by the data?What was the specific hypothesis around neuroticism that was not supported by the data?

H: Higher levels of the personality trait neuroticism would be associated with greater nocebo hyperalgesia (a larger increase in pain after the nocebo manipulation).

Why it wasn’t supported: There were no significant associations between neuroticism or any of the other personality factors and the change in either the Nocebo or the Natural history group.

(Aslaksen, P. M., & Lyby, P. S.) How could medical staff use the information from this study to inform their practice?

1. Screen for high fear of medical pain. It predicted nocebo hyperalgesia, so it can flag patients at risk of a stronger nocebo response.

2. Tailor care to those patients.

3. Treat nocebo as seriously as placebo

Which psychological mechanism is most closely associated with the placebo effect?

Classical conditioning through repeated associations.

What strategy can help reduce nocebo effects when communicating potential side effects?

Framing side effects as signs that the treatment is working

Placebo and nocebo research challenges health psychology theories by highlighting the importance of…

The role of unconscious, non-volitional processes in health behaviour and symptom experience.

(Yeomans et al., 2021) According to the authors, what are the two ways food can be rewarding, and how do they map onto liking and wanting?

Liking = hedonic reward. The immediate sensory experience of food, i.e., its pleasurable taste.

Wanting = incentive properties. The motivational desire for food, linked to the nutrients food provides.

(Yeomans et al., 2021) Why do the authors think it is difficult to use images of actual food in this type of research?

Mixed reward associations

Individual past experience

Broader memories and concerns

Unconscious associations

(Yeomans et al., 2021) What were the main aims of 1) Experiment 2 and 2) Experiment 2?

Experiment 1: to test whether novel visual cues associated with a linked sweet taste (vs a neural taste) alter voluntary intake of sweet and savoury snack foods, using a disguised intake test.

 

Experiment 2: To test whether cue-sweet training (a) attracts attention (dot-probe task), (b) increases liking for the cue, and (c) changes satiety expectations for products labelled with the cue.

(Yeomans et al., 2021) What were the exclusion criteria?

- Ever diagnosed with an eating disorder
- Diabetic
- Allergy or aversion to any ingredients in the snack intake test
- Smoked more than 5 cigarettes per week
- Prescription meds

(Yeomans et al., 2021)

(Yeomans et al., 2021) Briefly, how did they associate one visual cue with sweet and one visual cue with savoury, without explaining to participants what they were doing?

‘Odd-one-out’ cover task: participants were told to taste three cups and pick the one that differed in flavour.

Hidden key trials: On the two key trials per block, all three cups were identical, there was no real odd one out, so participants had to concentrate on the taste and just guess.

Cue on screen and cups: The relevant logo was shown on screen and printed on each cup, so it was paired with the taste.

Filler trials: 3 other trials per block had a clear odd-one-out to make the task look genuine.

Repetition: 5 blocks gave 15 pairings of each cue with its taste.

(Yeomans et al., 2021) Participants were assigned to have either the sweet-taste-associated logo or the neutral-taste-associated logo printed on the bowls at the time of the taste test. What sort of design is this, when participants are assigned to different conditions?

Between-participants (independent groups) design. Each participant only experienced one condition and were randomly assigned

(Yeomans et al., 2021) There is a legend missing from the figure! The black portion is the calories from savoury foods and the grey portion represents the calories consumed from sweet foods. What does this figure show about the role of the logos on consumption and the different types of food consumed?

The CSsweet logo increased overall intake, mainly of sweet foods, but the cue-by-food-type interaction was not significant (p = .072).

Intake was higher with the sweet-paired logo for both sweet and savoury snacks, so the cue boosted eating in general rather than clearly targeting sweet foods.

(Yeomans et al., 2021) “Experiment 1 provides evidence that a sweet-associated cue can in-

crease intake, but how these cues enhanced intake is still unclear.” What three possibilities do they want to test in Experiment 2?

Experiment 1: behavioural effect

Experiment 2: possible mechanisms.

1. Evaluative conditioning (liking): the CSsweet cue itself may have become more liked, which could in turn raise liking for the foods and increase intake. Tested with pre/post liking ratings of the cues.

2. Incentive salience (attention): The CSsweet cue may have become more salient and attract more attention, which facilitates intake Tested with a dot-probe attention task.

3. Satiety expectations: The brief sweet taste may have evoked memories of sweet foods, changing expectations about how filling products labelled with the cue would be. Tested with expected satiation and satiety ratings (satisfaction).

(Yeomans et al., 2021) Did they find that explicit liking of the cues was altered by being paired with a sweet taste?

No. Change in liking did not differ significantly between the CSsweet, CSneutral and control cues, with minimal changes in all 3 conditions.

 

Timing of the post-training ratings (before or after the dot-probe task) made no difference either, so extinction from repeated cue exposure doesn’t explain the null result.

(Yeomans et al., 2021) What is the main evidence that the incentive value of the sweet-paired cue had changed following conditioning?

The attentional bias in Experiment 2. Participants responded faster when the dot-probe appeared in the same location as the CSsweet cue.  Attentional bias is widely used as evidence of increased incentive salience of reward-associated cues.

Diets high in fruits, vegetables, and whole grains are associated with:

Better mental health outcomes

The term “food addiction” is controversial because:

It lacks a universally agreed definition and diagnostic criteria

Which brain region is central to regulating hunger and satiety?

Hypothalamus

Which gut hormone signals satiety after eating?

Cholecystokinin (CCK)

Ghrelin is often referred to as the:

Hunger hormone

The hedonic pathway of eating is primarily concerned with:

Pleasure and reward from food

The homeostatic pathway of eating ensures:

Maintenance of energy balance

Food cues such as branding and advertising are thought to:

Increase cravings and food consumption

Incentive salience theory suggests that:

Food cues can capture attention and trigger craving

A key limitation of public health nutrition campaigns is:

They may not change behaviour if environments remain obesogenic

Restricting junk food advertising to children is intended to:

Limit early exposure to persuasive food marketing

Evidence linking diet and cognition suggests that diets high in saturated fat and sugar

Impair learning and memory

Which of the following best reflects a population-level strategy rather than an individual intervention?

Regulation of portion sizes in fast food outlets

(Kelada et al., 2021) The authors list both negative and positive experiences of children whose siblings have a chronic illness. What are these?

Negative = Fear about their sibling's health, resentment about perceived loss of parental attention, ongoing distress, anxiety and anger

 

Positive = Increased empathy, closer ties with their affected brother/sister

(Kelada et al., 2021) What are the three distinct categories of young siblings’ caring responsibilities?

 

1.      Alert assistants: monitor their brother/sister and alert parents to a flare-up of symptoms.

2.      Substitute parents: take on the primary caring responsibility when parents aren’t available.

3.      Parenting assistants: help parents with caring responsibilities.

(Kelada et al., 2021) Why are cognitive processes identified as important in siblings’ mental health?

Siblings’ perception of differential treatment appears to be a particularly important determinant of their mental health. Siblings who perceive that their parents give them less attention than the affected sister/brother can experience poorer mental health.

 

This points to underlying cognitive processes (how siblings interpret or perceive their parents’ treatment) as potential protective factors.

(Kelada et al., 2021) What are the most commonly reported coping strategies and are these optimal?  

What is related to better psychological functioning?

Avoidant coping strategies: distraction, compartmentalisation and blaming others.

 

Not optimal, as whilst they may relieve distress in the short term, they are related to longer-term mental health concerns among siblings.

 

Problem-focused coping may be related to better psychological functioning.

(Kelada et al., 2021) What is the brief COPE?

A versatile measure of coping strategies.

The study looked at 2 types: avoidant coping: distraction, denial, giving up.

Problem-focused coping: actively tackling the problem, getting support, planning.

 

Siblings rated how much they use each one, 1 (“I don’t do this at all) to 4 (“I do this a lot”).

(Kelada et al., 2021) According to the table, what sort of support would you class most of these as: emotional, instrumental or informational care?

Instrumental care. Most items are practical, hands-on tasks: Looking after them, helping with meds, cleaning up, preparing meals, helping dress, eat, bathe.

(Kelada et al., 2021) Siblings engaged in caring responsibilities reported lower anxiety symptoms – what was the mean score for those who did not care vs. did care for their ill siblings?

Never/hardly ever mean anxiety score = 5.50 (SD = 2.57)

Sometimes to very often mean anxiety score = (SD = 2.14)

The difference was significant. Anxiety was measured on the 10-point emotion thermometer

(Kelada et al., 2021) Were scores on the psychosocial functioning questionnaire different for those who engaged vs. did not engage in caring?

No. Caring responsibilities were not significantly related to psychological functioning, and the same was true for physical functioning. Perceived differential parental affection was the significant predictor.

(Kelada et al., 2021) The authors report that “Anxiety and need for help were lower in siblings who reported having caring responsibilities for

their affected brother/sister, compared with siblings who did not have such caring responsibilities.” Why do you think this is? Were you surprised by this finding?

Prosocial benefit: Prosocial behaviour is linked to better mental health and relationships, and caring siblings also had more companionship with their affected sibling.

 

Helplessness: Siblings not involved in caring may feel helpless or have an external locus of control; both linked to poorer mental health.

Reverse direction

Problem-focused coping

(Kelada et al., 2021) What do you think is one take-home message that could be taken from this section, and given as advice to parents?

Involve your well children in caring for their sibling, and make sure they feel loved and valued while doing it.

What does HRQOL stand for?

Health-Related Quality of Life

Which of the following is a factor influencing quality of life in chronic illness?

Social Support

Post-traumatic growth refers to:

Positive psychological change after adversity

What is caregiver burden?

Emotional and physical stress experienced by caregivers

What type of coping involves managing emotions rather than solving the problem?

Emotion-focused coping

Who is most likely to experience caregiver burden?

Family members providing long-term care.

What is Lepore’s model

A psychological framework that explains how the social environment directly influences an individual’s ability to cognitively process and psychologically adapt to traumatic or highly stressful life events.

In Lepore’s model, adjustment involves

Cognitive and emotional processing of illness

Which of the following contributes to post-traumatic growth?

Meaning-making

Families copying with adult cancer often experience

Role changes and emotional stress

(Jones et al., 2023) How many people in Australia receive an opioid as first-line treatment when presenting with back or neck pain? Why is this a surprising figure?

2/3rds. Clinical guidelines recommend opioids for acute low back or neck pain only when other pharmacological treatments haven’t worked, so opioids should not be first in line.

 

There is also no direct, robust evidence supporting their use for these conditions, and they carry risk of serious adverse events (overdose).

(Jones et al., 2023) The authors describe this as a ‘triple-blinded’ RCT. What does that mean?

Triple-blinded means three groups didn’t know who got the opioid and who got the placebo.

Participants, trial doctors and outcome assessors and data analysts all didn’t know.

(Jones et al., 2023) Why did eligible participants need to have the current episode of pain for 12 weeks or less and be preceded by at least 1 month free from pain?

The trial targeted acute pain.

Makes sure the episode is a new one, not a flare-up of ongoing or chronic pain

(Jones et al., 2023) What steps did they take to try and reduce the likelihood that participants would compromise the study?

1. Advice to participants: All participants were advised not to take non-study opioids during the intervention period. This reduces the change that outside opioids (e.g. in the placebo group) would blur the difference between groups.

 

2. Guideline care: Both groups received the same guideline-recommended care: reassurance of positive prognosis, advice to stay active and avoid bed rest, and non-opioid analgesics if required. This means the only planned difference between groups was the tablet.

(Jones et al., 2023) The ‘primary endpoint’ of the study was the difference between the placebo and opioid groups in reported pain intensity, after 6 weeks. They estimated that a difference of 1 on the 10-point scale would be the ‘minimal clinical difference’ between groups. What does this mean?

The minimal clinical difference is the smallest difference in pain score that would be big enough to matter in real life.

A difference can be statistically significant but too small to matter to patients. By setting a threshold in advance, the trial asks whether opioids help by a meaningful amount, not just whether any difference exists.

(Jones et al., 2023) What can we say about the overall difference between the 2 groups at each of the bi-weekly  pain ratings?

Both groups improved a lot, and the opioid group’s pain was slightly higher than placebo at every time point after baseline.

(Jones et al., 2023) Despite what it looks like in the figure, was there a statistically significant difference between the pain and opioid groups in their self-reported pain at week 6? What about week 12?

Week 6: No. Mean difference 0.53

Week 12: No. Mean difference 0.48.

At week 52, the difference did reach significance, favouring placebo.

(Jones et al., 2023) The authors report some important checks they performed. Specifically, they report that there was no significant difference between groups in overall health-care use over the course of the study, adverse events during the study or compliance. Why it is important to check that these factors did not differ between groups?

Because these differences could explain the pain results, checking them shows the group difference is due to the tablet

(Jones et al., 2023) How many participants correctly guessed which group they were in? Are you surprised?

Correctly guessed they were in the opioid group: 29 of 122 (24%)

Correctly guessed they were in the placebo group: 37 of 118 (31%) 

Surprising? A little, most participants (52% opioid, 54% placebo) didn’t know which group they were in. The opioid group was no better at spotting their treatment, even though opioids cause side effects like nausea, constipation and dizziness that could give it away ; this suggests blinding worked well

(Jones et al., 2023) Compliance was an issue, with around only half of participants taking at least 80% of the prescribed medication. Why do the authors think this is not such a huge issue?

Because compliance was similar in both groups and the level matches real-world practice.

(Jones et al., 2023) On balance, why do the authors argue that opioids should not be prescribed for acute back or neck pain?

Because opioids showed no benefit but carried a risk of harm.  No benefit; slightly worse long-term and short-term side effects of nausea, constipation, and dizziness and long-term misuse risk.

What distinguishes pain as a symptom rather than a sign?

It is a subjective experience reported by the patient.

Which type of pain results from damage or dysfunction in the nervous system?

Neuropathic pain

What characterises chronic or persistent pain?

Pain lasting longer than 3 months.

What does the ‘gate control theory’ of pain propose?

Pain signals can be modulated by the spinal cord before reaching the brain.

What is a primary feature of nociplastic pain?

Pain without clear evidence of tissue damage or nerve injury.

What factors are included in the biopsychosocial (5Ps) assessment model?

Presenting Problem

Predisposing Factors

Precipitating Factors

Perpetuating Factors

Protective Factors

What does ‘fear-avoidance’ behaviour lead to in chronic pain?

Increased disability and pain persistence.

What is an example of an active pain management strategy?

Mindfulness-based stress reduction.

What is true of nociceptive pain?

It is caused by actual or potential tissue damange.

Why is pacing important in chronic pain management?

It prevents overexertion and flare-ups.

(Watanabe et al., 2018) What is metabolic syndrome?

A cluster of medical conditions that together raise the risk of cardiovascular disease and type 2 diabetes.

(Watanabe et al., 2018) The authors only included ‘prospective’ studies. What does this mean?

Prospective studies follow people forward over time. Participants are assessed at the start and then followed to see how the outcome develops later.

 

The authors say targeting only prospective studies gives the strongest evidence at present, because exposure comes before outcome. This shows causation rather than just correlation.

(Watanabe et al., 2018) What type of stress exposures (e.g., occupational, marital, general perceived stress) are being studied here. Are any two studies measuring the same sort of stress?

Types of stress: Occuptational psychosocial factors, not marital or general perceived stress.

 

Yes, the same sort of stress measured was  job strain and shift work.

(Watanabe et al., 2018) Some studies looked at the relationship between stress and metabolic syndrome after controlling for demographic or lifestyle factors. What exactly were these factors?

Demographic variables: age, sex, education and marital status.

Lifestyle variables: smoking, physical activity and sleep

(Watanabe et al., 2018) In this figure, the black vertical line at 1 indicates an odds ratio of 1, where the odds of having metabolic syndrome after stress exposure is no greater or less than 1. You can see that some studies’ horizontal line (presumably showing the mean and 95% confidence interval but missing from the figure caption!) are sitting to the left of this black line, and some are to the right. What does it mean if a study’s mean odds ratio is to the left or the right of 1?

To the left of 1: A negative association. Workers exposed to work stress had a lower risk of developing metabolic syndrome than unexposed workers.

To the right of 1: A positive association. Exposed workers had a higher risk of developing metabolic syndrome.

(Watanabe et al., 2018) The red dotted line and blue shape represent the pooled effect size for all the studies. What can we say about the association between work stress overall and the likelihood of developing metabolic syndrome?

Overall, adverse work-related stress is associated with a higher likelihood of developing metabolic syndrome.

 

Strong positive association.

(Watanabe et al., 2018) The authors performed two sub-group analyses, looking at the relationship between a) job strain and metabolic syndrome and b) shift work and metabolic syndrome. Which one of these stress exposures was more strongly related to the development of metabolic syndrome?

Job strain was more strongly related.

 

Shift work was slightly weaker than job strain, though both were positive and significant.

(Watanabe et al., 2018) What are the possible physiological and behavioural mechanisms that might explain the relationship between work stress and metabolic syndrome? How do these map to direct and indirect effects?

Physiological/neuroendocrine effects of stress: Sympathetic nervous system. Stressors raise cortisol, which increases insulin resistance, then visceral fat accumulation, ending in abdominal obesity.

 

Behavioural effects of stress: Diet, ‘stress eating’, physical inactivity, smoking and drinking

The HPA-axis route ‘the direct effect’ and behavioural routes ‘indirect effecs’

(Watanabe et al., 2018) Why could the authors not look to see whether there were differences in the relationship between work stress and metabolic syndrome as a function of gender? Why might this have been an important factor to look at?

They couldn’t because there was a shortage of stress-stratified results in the studies, so they couldn’t investigate sex-stratified associations.

 

Differences in hormone functions, may be important variables.

(Watanabe et al., 2018) How could you use the information from this meta-analysis to give people advice on careers and work stress? 

Work stress, especially job strain and shift work, is linked to a higher risk of metabolic syndrome, so it’s worth weighing these.

What best defines stress as a stimulus?

Stress is the result of external or life changes.

What is life events theory?

A stimulus-based model stating that major life changes, both positive and negative - require psychological and biological adjustment.

What is a major criticism of live events theory?

It does not account for individual differences in perception.

Secondary appraisal refers to

Assessment of available coping resources.

Which hormone is primarily released during HPA axis activation?

Cortisol

How can stress negatively impact the immune system?

By suppressing immune responses over time.

What is an indirect pathway linking stress to illness?

Poor sleep quality caused by anxiety.

What are the Big Five (Luo et al., 2023), and how do they influence stress?

Openness to experience
Conscientiousness
Extraversion
Agreeableness
Neuroticism (proneness to negative emotions)

Both directly and indirectly

(Griffiths et al., 2024) According to the authors, what is the end goal of social media algorithms and how is this defined?

End goal: user engagement.

Engagement is straightforwardly interpreted as more time spent on the platform.

(Griffiths et al., 2024) According to the authors what are the limitations of existing research on social media and eating disorders?

Research has struggled to capture a full picture of users’ actual social media experience.

Studies have mainly relied on
1. Self-report surveys about general social media use

2. Experimental exposure studies, where researchers pre-select content and show it to participants in controlled settings.
3. Content analyses of qualitative aspects of social media content.

(Griffiths et al., 2024) What are the two main hypotheses and the third confirmatory hypothesis being tested in this study?

1.      Users with eating disorders would be shown more appearance-oriented, dieting, exercise and toxic eating disorder videos than users without eating disorders.

2.      Biases in users’ algorithms towards these video types would be positively correlated with eating disorder symptoms.

Third confirmatory hypothesis: Users’ ‘liking’ behaviour would contribute to the likelihood of their algorithm delivering these types of videos.

(Griffiths et al., 2024) In simple language and no more than two sentences explain how the researchers got access to and categorised the TikTok videos delivered to each participant.

Participants requested their own TikTok data (which lists the links to every video their algorithm delivered), and the researchers used those links to automatically collect each video’s hashtags and whether it was liked.

 

A script then sorted each video into categories by matching its hashtags to lists the researchers had built.