The placebo debate continues to rear its head and provoke heated discussion following the publication of a randomised controlled trial in the United Kingdom involving patients with irritable bowel syndrome.1 Researchers set out to determine if placebo effects can be separated into the responses by patients to three components of a placebo medical encounter. A total of 262 adults (76% women) with irritable bowel syndrome were randomly assigned to three groups: waiting list (observation); placebo acupuncture alone (limited); or placebo acupuncture in which the patient-practitioner relationship was accompanied by warmth and attention (augmented). After 3 weeks, participants completed a global improvement scale and symptom severity assessment. Researchers hypothesised that the factors contributing to the placebo effect can be progressively combined in a way resembling a graded dose escalation. The outcome measures showed a trend: a significant increase in the reported improvement of symptoms as the three components of the placebo effect were progressively added. Enhancing the patient-practitioner relationship component appears to be the most significant factor in the observed improvement. The authors acknowledge the limitations of their study, including the subjective nature of the outcome measures, and call for further research into the components of the placebo effect. Spirited debate among the medical community has ensued, raising interesting questions about the nature of the therapeutic relationship.2
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