Placebo – og derfor virker det

Placebo

 

Placebo er ganske enkelt den mest effektive medicin, som mennesket nogensinde har anvendt.

Af Lene Pilegaard

Hvad er placebo?

  • Ordet stammer fra det latinske ord ”placeo” – jeg behager.
  • Placebomedicin er udviklet til kontrol af virksom medicin.
  • Placebo benyttes i den medicinske terminologi som betegnelse for en medicinsk neutral behandling, dvs. at der ikke gives et medicinsk præparat. Det kan for eksempel være en behandling med tabletter, der indeholder sukker, laktose eller kalk eller injektioner med fysiologisk saltvand.
  • Den almindelige opfattelse og det almindelige udtryk for placebo er “snydemedicin”.
  • Placebobehandling har vist objektive fysiologiske forandringer, lige fra forandringer i hjerterytme, blodtryk og aktivitet i hjernen ved flere symptomer som smerter, depression, angst, træthed, visse symptomer ved Parkinson’s sygdom.
  • Patienter, der får placebo – enten medicin (kalktabletter) eller anden behandling som dokumenterbart ikke virker – vil alligevel kunne opleve en helbredsmæssig forbedring. Det kaldes placeboeffekt.

Hvad er placeboeffekt?

Effekten kan både forstås snævert som ”kalktableteffekten”’, men også bredere som effekten af behandlingsritualet, mødet mellem læge og patient eller omgivelserne. Den bredere definition ser på den samlede effekt af behandlingskonteksten.

Effekten af en behandling påvirkes derfor af patientens tidligere erfaringer og (tillærte) forventninger. Disse kan være både positive (placebo) og negative (nocebo). I tillæg hertil spiller bl.a. konteksten, gensidig tillid, empati og troværdighed samt kommunikative evner en stor rolle for den patientoplevede effekt af en behandling.

Placeboeffekten opfattes i almindelighed som de subjektive og/eller objektive positive ændringer, der fin- der sted efter udsættelse for en placebobehandling. Denne effekt tilskrives en række forskellige psykologiske og biologiske forhold, såsom graden af patientens håb, motivation og tidligere positive erfaringer, et positivt forhold mellem læge og patient (opmærksomhedsplacebo) samt udskillelse af endogene endorfiner.

Placebo virker ved visse sygdomme – også når patienterne ved, de får snydemedicin.

Normalt bruges placebopiller til medicinske forsøg, hvor hverken lægen eller patienten ved, om pillerne indeholder virksomt stof eller ej. Når der er en gavnlig virkning i kontrolgruppen, kaldes dette for placeboeffekten.

Nocebo er, når man oplever negative virkninger fra virkningsløs medicin.

Hvad har placeboeffekt med smertelindring at gøre?

Der er et helt apotek i os alle. Kroppen kan ikke tænke kræftceller og andre mekaniske sygdomme væk, men vi har i hjernen mekanismer, som kan aktivere kroppens egne ”medikamenter”, og de er i stand til at modificere graden af symptomer, for eksempel smerter, træthed og angst.

Den lyttende, empatiske læge eller anden behandler har store positive konsekvenser for vores oplevelse af kroppens faresignaler og selvoplevede symptomer.

Hjernens plasticitet spiller ind

Komplekse langvarige smertetilstande ender ofte med at blive en tilstand, hvor sygdom og lidelse får førsteprioritet over vores bevidsthed. Det vil betyde, at andre ting må glide i baggrunden. Arbejdet, vennerne, tosomheden i parforholdet eller evnen til at koncentrere sig om at læse en bog for at nævne nogle eksempler.

Det er ikke svært at forestille sig, at mennesker, der oplever dette, let kan være på vagt over for store og små forandringer i deres krop. Forandringer og fornemmelser, som bevidstheden vil forsøge at finde en rationel forklaring på. Og desto mere man ”øver sig” i at være opmærksom på og fortolke kroppens signaler – desto bedre bliver man til det. Alt sammen som et resultat af hjernens såkaldte plasticitet.

Patienten kan selv være både sin egen medicin, men også forværre oplevelserne af sygdom.

Hjernen kan individuelt forstærke eller formindske oplevelser af kroppens signaler

Vi kender det alle fra vores dagligdag, hvor vi kan opleve smerter vidt forskelligt, alt efter hvordan man ellers har det, og hvor bekymret man er for det, der udløste smerten. Derfor spiller vores personlige oplevelser af symptomer en langt større rolle for oplevelse af vores sundhedstilstand.

Smerte og andre symptomerne efter for eksempel et lårbensbrud eller kræft er altså ikke en objektiv ensartet størrelse, der bearbejdes på samme måde i alle menneskers hjerner ud fra de signaler, hjernen modtager fra det syge sted.

Den enkelte spiller altså selv en central rolle for oplevelsen af kroppens symptomer. Er man angst og bekymret og sidder i timevis og fokuserer på sine smerter, kan det virke selvforstærkende. Det er ikke, fordi man bilder sig smerterne ind. Smerteoplevelsen er reel, men man kan selv have indflydelse på, hvordan symptomerne opleves.

Placeboeffekter er et interessant fænomen i forbindelse med oplevelsen af kropslige symptomer, og hvordan de så bliver bearbejdet i hjernen.


Behandleren er også medicin

Forskning i placeboeffekt viser, at ”lægen eller behandleren er et medikament”, der sammen med patienten selv kan have afgørende indflydelse på graden af de oplevede kropslige symptomer.

Man har kunnet påvise, at lægen eller anden behandler øver indflydelse, så den gode tillidsskabende læge kan medvirke til, at hjernen frigør symptomdæmpende stoffer.

Det kan skyldes, at man i dag i vores kulturkreds generelt accepterer den form for ritualer som behandling og derfor i mødet med behandleren selv frigør de symptomlindrende stoffer i hjernen. Behandleren, lægen eller den alternative behandler/behandling spiller en ret central rolle, og patienter, der føler sig set, får et bedre sygdomsforløb end patienter, der føler, at lægen eller behandleren ikke lytter, uanset om lægen gør noget eller ej. Så behandling er ikke kun den medicin, som lægen giver, men også selve mødet med lægen og hele konteksten omkring behandlingen. Det er denne samlede virkning man kalder placebo- eller konteksteffekten.

Lægens facon er afgørende

Det afgørende er dog ikke kun behandlingsmetoden. Nok så vigtig er lægens fremtræden og væremåde. En læge, der udstråler autoritet og virker optimistisk i forhold til behandlingen, får større succes med sin behandling end en læge, der virker ligeglad, usikker eller utroværdig.

Troen på, at det virker

Det er velkendt, at blot troen på, at en behandling virker, kan give en positiv effekt. Hjernescanninger har vist, at der frigives smertelindrende stoffer – endorfiner – fire steder i hjernen, når forsøgspersoner fik placebomedicin. Både hjernen og kroppen reagerer fysisk og placebo kan udløse de samme biokemiske reaktioner som almindelig medicin.

Vi ved af erfaring, at hovedpinen forsvinder i løbet af en halv times tid, hvis vi tager en hovedpinepille, for vi har prøvet det før. Virkningen skyldes i høj grad den smertelindrende effekt af pillens aktive stof, fx acetylsalicylsyre eller paracetamol. Men det er ikke hele forklaringen. Vores forventning om, at smerterne snart vil lette, er så stærk en kraft, at den helt af sig selv kan gøre drømmen til virkelighed.

Undersøgelser viser, at placebo virker på to måder: Enten ved at vi nærer et stærkt ønske om, at det skal virke, eller fordi man har prøvet det før.

Forventning om smertelindring

Med PET-scanninger (PET = positron emission tomografi) kan man måle mængden af de såkaldte endorfiner, som er hjernens eget smertestillende middel, der minder om morfin. Ved forsøg har man kunnet måle øget endorfinaktivitet hos personer, der fik at vide, de efterfølgende ville få smertelindrende medicin, mens de blev scannet. Så her steg aktiviteten alene ud fra forventningen om, at deres smerter ville blive lindret, og personerne følte mindre smerte og ubehag allerede før, at hverken ”rigtig” eller placebomedicin var indtaget. Forsøget viste, at placeboeffekten ikke bare er indbildning, men at hjernen reagerer rent fysisk og dæmper følelsen af smerte.

Placebo kan give de samme biokemiske reaktioner som rigtig medicin.

Betingede reflekser

Husker du Pavlovs hunde, der savlede, når de troede, at de skulle spise? Det kaldes betinget refleks. Konsekvensen af betinget refleks (klassisk konditionering) er, at et stimuli (Pavlovs klokke), der normalt ikke har noget med mad at gøre, kan fremkalde savl hos hundene.

Det samme kan gælde for mennesker! Nu er det hverken klokker eller mad, der indgår i (normal) behandling af smerter, men påvirkning af produktion og tilgængelighed af bestemte neurotransmittere (signalstoffer i hjernen). Forsøg har vist, at patienter, der oplever effekt efter første behandling, er tilbøjelige til at få større effekt efter anden behandling end patienter, der ikke oplever effekt efter første behandling.

Det, der kan forklare dette boost i placeboeffekt, antages at være det såkaldte belønningssystem i hjernen, hvor produktion og fordeling af dopamin (neuropeptid (lykkehormon)) er involveret.

Eksempelvis viste et gennembrudsstudie af patienter med Parkinson’s sygdom i Nature i 2001, at de patienter, der fik placebomedicin, men troede, at det var deres normale medicin, frigav stoffet dopamin i hjernen svarende til 250 mg aktiv medicin.

Hjernen kan altså udløse komplekse neurobiologiske mekanismer og afsende signalstoffer, når vi møder den gode behandler eller læge og ”snydes” ved placebobehandling.

Dyre piller virker bedst

En kostbar smertestillende pille virkede bedre end en billig smertestillende pille i et forsøg. Selv om begge piller kun indeholdt sukker.

Det lyder irrationelt og muligvis dumt – men det virker bedre at betale overpris for en behandling end at få den på tilbud.

Patienter rapporterer, at de falder væsentligt hurtigere i søvn og sover længere efter at have taget blå (placebo) tabletter end efter at have taget tilsvarende orange tabletter. Røde tabletter virker også bedre som smertestillende end tilsvarende hvide, blå eller grønne placebo tabletter.

Forskere fra Massachusetts Institute of Technology – MIT – har i et eksperiment fundet ud af, at folk, der bliver udsat for smerte, føler, at dyre piller virker mere smertelindrende, også selv om pillen egentlig er et placebomiddel – en uvirksom sukkertablet.

Med andre ord forventer folk, at en dyr pille virker mere effektivt end en billig – og derfor er den også mere effektiv. Forsøget viser, at der ud over en generel placeboeffekt er en pris-placeboeffekt.

Det viser, at placeboeffekten er afhængig af den information, der er omkring præparatet. Prisen og renommeet er meget betydningsfuldt for, hvordan man oplever effekten af det.

To er bedre end en

På baggrund af mange forsøg viser det sig, at store kapsler virker bedre end små, røde piller bedre end hvide piller, og mange piller virker bedre end kun en enkelt pille.

Farven på piller har betydning

I vores vestlige del af verden sælges der flest røde, orange og gule piller, som har med stimulation af nervesystemet at gøre, mens der bliver solgt flere blå, grønne og lilla tabletter, som skulle virke sløvende, dæmpende eller mod depression. Det bunder i en masse forskning, der så er udmøntet i medicinalfirmaernes valg af farve på piller, så de får bedst mulig effekt.

Information om bivirkninger

Jo flere og mere angstvoldende oplysninger patienten får om, at et præparat kan medføre bivirkninger, jo flere patienter oplever bivirkninger. Derfor kan den enkelte både være med til at dæmpe egne symptomer, oplevelsen af smerter eksempelvis, ligesom den enkelte kan være med til at øge oplevelsen af de generende symptomer.

Studier har eksempelvis vist, at mellem fire og 26 procent af alle de patienter, der får virkningsløse kalk- tabletter i videnskabelige medicinforsøg, dropper ud af studierne, fordi de oplever bivirkninger. Fra virkningsløse kalktabletter.

Man kan ikke tænke bakterier eller virusinfektioner væk, hele brækkede knogler hurtigere ved tankens kraft eller slå kræftceller ihjel, fordi vi ønsker det. Men vi kan være med til at få vores generende og måske ligefrem invaliderende smertesymptomer eller søvnproblemer under kontrol.

Styrk læge-patient-forholdet

Meget tyder på, at positive forventninger, herunder en positiv relation mellem læge og patient, har en stor betydning for patientens helbred. Men i vores fortravlede tid har en læge kun lidt tid til hver patient, hvad enten det drejer sig om hospitaler eller privatpraksis.

Måske kunne det ligefrem betale sig, at man skabte steder, der tilgodeser, at læge-patient-forholdet bliver styrket, så den positive forstærkende effekt af relationen bliver udnyttet?

”Læg et puslespil, og glem smerterne”

Puslespil kombineret med placeboeffekt lindrer smerterne mere effektivt end hver af effekterne alene.

Læg et puslespil! Det kan hjælpe dig til at glemme smerterne. En effekt, mange kender, men nu også understreget af et forsøg med en yderligere interessant konklusion. Ud over distraktioner som puslespil kan også placebo mindske smerten ved at skabe en forventning om lettelse.

Men bruger placebo og distraktion de samme hjerneprocesser?

Neuroimaging, hvor man populært sagt filmer hjernen undervejs, antyder, at de gør. Ved at tilbyde smertepatienter uvirksom medicin (placebo) har forskere kunnet konstatere aktivitet i den præfontale cortex – den forreste del af hjernen, der styrer avancerede kognitive funktioner som hukommelse og opmærksomhed – netop de funktioner, du bruger til at lægge det distraherende og opmærksomheds- krævende puslespil.

Personer i forsøget med placebomedicin for smertelindring oplevede mindre smerte, når de samti- dig var dybt koncentreret og optaget – i det tilfælde med en svær hukommelsesopgave. Det viser, at placebo og distraktion komplementerer hinanden. Forsøget tyder derfor på, at placeboeffekten ikke udnytter avancerede kognitive funktioner og det med fordel kan bruges sammen for at maksimere effekten mod dine smerter uden medicin.

Tro på effekten

  • Jo mere du tror på symptomlindrende effekt, jo bedre virker den ægte medicin og behandling, du modtager.
  • Ofte er det dine symptomer, som en læge eller behandler skal mindske – smerter, kvalme, træthed, depressive tanker, angst, nervøsitet.
  • Symptomer er stærkt påvirket af dine forventninger til og tro på effekten af en given hjælp, ligesom de kliniske omgivelser også påvirker en behandling.

Fokuser på de positive virkninger

Nocebo er det modsatte af placebo, altså hvor du oplever negativ effekt, hvor den rettelig ikke er. Frygter du eksempelvis bivirkninger fra en medicinsk behandling, vil du oftere opleve negative symptomer som følge af behandling/medicin.

Patienter, der oplyses om seksuelle bivirkninger ved en medicinsk behandling, vil i forsøg sige, at de oplever seksuelle bivirkninger. Forskere formoder derfor, at en del, der behandles for medicinske bivirkninger, i virkeligheden oplever noceboeffekter.

Find empatisk læge/behandler

Jo bedre forhold en patient har til sin behandler eller læge, jo bedre vil symptomer som smerte, nervøsitet, søvnproblemer blive lindret.

Du kan ikke tænke dine kræftceller væk

Placebo helbreder ikke biologiske lidelser. Hverken placebotabletter, en empatisk behandler, de rette omgivelser og behandlingsritualer kan kurere infektioner, kræft, diabetes eller knoglebrud og lignende mekaniske sygdomme.

Men placebo kan have modererende effekt på de symptomer, som afstedkommes af en sygdom, for eksempel en kræftlidelse.

Lad tiden gå

Tid skal ikke forveksles med placeboeffekt, men vil i rigtig mange tilfælde være forklaringen på, at en behandlerindsats har virket.

De fleste symptomer som smerter og let depression mindskes eller forsvinder helt naturligt over tid, ligesom mange biologiske virus- og bakterieinfektioner har et naturforløb, hvor kroppen selv bekæmper sygdommen.

Kilder:

Illustreret Videnskab, nr. 7, 2006 – ”Derfor har placebo effekt” – artikel af Gorm Palmgren www.videnomsmerter.dk – Placebo – terapi er belønning i hjernen

Moerman, Daniel: Meaning, medicine and the placebo effect, 2002

Benedetti, Fabrizio: Placebo effects – understanding the mechanisms in health and disease, 2009

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