This paper aims to provide a theoretical framework for explaining the subjective character of pain experience in terms of what we will call ‘embodied predictive processing’. The predictive processing (PP) theory is a family of views that take perception, action, emotion and cognition to all work together in the service of prediction error minimisation. In this paper we propose an embodied perspective on the PP theory we call the ‘embodied predictive processing (EPP) theory. The EPP theory proposes to explain pain (...) in terms of processes distributed across the whole body. The prediction error minimising system that generates pain experience comprises the immune system, the endocrine system, and the autonomic system in continuous causal interaction with pathways spread across the whole neural axis. We will argue that these systems function in a coordinated and coherent manner as a single complex adaptive system to maintain homeostasis. This system, which we refer to as the neural-endocrine-immune (NEI) system, maintains homeostasis through the process of prediction error minimisation. We go on to propose a view of the NEI ensemble as a multiscale nesting of Markov blankets that integrates the smallest scale of the cell to the largest scale of the embodied person in pain. We set out to show how the EPP theory can make sense of how pain experience could be neurobiologically constituted. We take it to be a constraint on the adequacy of a scientific explanation of subjectivity of pain experience that it makes it intelligible how pain can simultaneously be a local sensing of the body, and, at the same time, a more global, all-encompassing attitude towards the environment. Our aim in what follows is to show how the EPP theory can meet this constraint. (shrink)

Unlike its friendly cousin the placebo effect, the nocebo effect (the effect of expecting a negative outcome) has been almost ignored. Epistemic and ethical confusions related to its existence have gone all but unnoticed. Contrary to what is often asserted, adverse events following from taking placebo interventions are not necessarily nocebo effects; they could have arisen due to natural history. Meanwhile, ethical informed consent (in clinical trials and clinical practice) has centred almost exclusively on the need to inform patients about (...) intervention risks with patients to preserve their autonomy. Researchers have failed to consider the harm caused by the way in which the information is conveyed. In this paper, I argue that the magnitude of nocebo effects must be measured using control groups consisting of untreated patients. And, because the nocebo effect can produce harm, the principle of non-maleficence must be taken into account alongside autonomy when obtaining (ethical) informed consent and communicating intervention risks with patients. (shrink)

The placebo effect is now generally defined widely as an individual’s response to the psychosocial context of a clinical treatment, as distinct from the treatment’s characteristic physiological effects. Some researchers, however, argue that such a wide definition leads to confusion and misleading implications. In response, they propose a narrow definition restricted to the therapeutic effects of deliberate placebo treatments. Within the framework of modern medicine, such a scope currently leaves one viable placebo treatment paradigm: the non-deceptive and non-concealed administration of (...) “placebo pills” or open-label placebo (OLP) treatment. In this paper, I consider how the placebo effect occurs in OLP. I argue that a traditional, belief-based account of OLP is paradoxical. Instead, I propose an account based on the non-doxastic attitude of pretence, understood within a fictionalist framework. (shrink)

Predictive processing has begun to offer new insights into the nature of conscious experience—but the link is not straightforward. A wide variety of systems may be described as predictive machines, raising the question: what differentiates those for which it makes sense to talk about conscious experience? One possible answer lies in the involvement of a higher-order form of prediction error, termed expected free energy. In this paper we explore under what conditions the minimization of this new quantity might underpin conscious (...) experience. Our suggestion is that the minimisation of Expected Free Energy is not in itself sufficient for the occurrence of conscious experience. Instead, it is relevant only insofar as it helps deliver what Ward et al. ( 2011 ) have previously described as a _sense of our own poise over an action space_. Perceptual experience, we will argue, is nothing other than the process that puts current actions in contact with goals and intentions, enabling some creatures to know the space of options that their current situation makes available. This proposal fits with recent work suggesting a deep link between conscious contents and contents computed at an ‘intermediate’ level of processing, apt for controlling action. (shrink)

According to L. A. Paul, the subjective value of an outcome is normally assessed by running a cognitive model of what it would be like if that outcome were to occur. However, cognitive models, along with the expectations in which they result, are unreliable for application to transformative experiences because we cannot know what it would be like for an outcome to occur if we have never experienced it before. This paper argues that despite their unreliability, expectations are still important (...) in the case of chosen and unchosen transformative experiences because expectations about an outcome can systematically influence the very experience of that outcome. More precisely, empirical research shows that affective experiences tend to assimilate to affective expectations. In turn, more positive affective experiences lead, ceteris paribus, to higher subjective value. Therefore, rational agents confronting transformative outcomes should form or cultivate positive/optimistic affective expectations since, all else being equal, that maximizes subjective value. (shrink)

Unlike its friendly cousin the placebo effect, the nocebo effect has been almost ignored. Epistemic and ethical confusions related to its existence have gone all but unnoticed. Contrary to what is often asserted, adverse events following from taking placebo interventions are not necessarily nocebo effects; they could have arisen due to natural history. Meanwhile, ethical informed consent has centred almost exclusively on the need to inform patients about intervention risks with patients to preserve their autonomy. Researchers have failed to consider (...) the harm caused by the way in which the information is conveyed. In this paper, I argue that the magnitude of nocebo effects must be measured using control groups consisting of untreated patients. And, because the nocebo effect can produce harm, the principle of non-maleficence must be taken into account alongside autonomy when obtaining informed consent and communicating intervention risks with patients. There are no data in this work. (shrink)

Philosophical debates about how best to explain emotion or placebo are debates about how best to characterise and explain the distinctive form of human responsiveness to the world that is the object of interest for each of those domains of inquiry. In emotion research, the cognitive theory of emotion faces several intractable problems. I discuss two of these: the problem of epistemic deficit and the problem of recalcitrant emotions. Cognitive explanations in Placebo Studies, such as response-expectancy and belief-based explanations, also (...) face the problem of epistemic deficit in addition to the problem of logically self-destructive true belief. While such considerations might motivate a retreat to affect, this brings its own problems. I argue that it is a particular version of cognitivism, representational cognitivism (Rep-Cog), that generates the paradoxes we encounter in emotion and placebo research. I propose that turning to nonrepresentational accounts of cognition will dissolve these paradoxes. As I move toward conclusion, I propose drawing on the ethnomethodological tradition to respecify human responsiveness to loci of significance in the lifeworld by undertaking ethnographies of members’ own situated methods for making intelligible and accountable their attitudinal and nonattitudinal responsiveness to loci of significance in their environment. (shrink)

In the field of placebo studies residual disagreement about the terminology ‘placebo’ and ‘placebo effect’ still persists. We differentiate between the conceptualization of placebos in clinical trials; and placebo effects understood as a psychobiological phenomenon. With respect to the latter, we argue that a scientific ‘placebo paradigm’ has emerged, indicating that—at least among placebo scientists—there exists relatively stable consensus about how to conceive of placebo effects. We claim that existence of a placebo paradigm does not protect concepts from revision; nonetheless, (...) we argue that scientific progress is dependent on, and guided by relative conceptual stability. Therefore, to mount persuasive arguments for conceptual revision in respect of ‘placebo effects’ we argue, critics either need to defend the claim that a placebo paradigm is not underway, or that there are major scientific failings in respect of it. With these considerations in mind we examine three alternative proposals for conceptual reform: Grünbaum/Howick’s relativity models of placebo concepts; Moerman/Brody’s meaning response; and Nunn/Turner’s proposal for conceptual eliminativism. We derive two conclusions from this evaluation. First, we conclude that no convincing arguments have so far been presented for conceptual overhaul of ‘placebo effects.’ Notwithstanding this analysis, we conclude that refinement of this concept is likely. Second, we agree with Turner and Nunn that the term ‘placebo’ in the context of randomized controlled trials remains a source of confusion for many researchers, risking the design and scientific integrity of clinical findings. Therefore, in these contexts, replacing the term ‘placebo’ with ‘control’ is justified. (shrink)

Osteopathy is a person-centred healthcare discipline that emphasizes the body’s structure-function interrelationship—and its self-regulatory mechanisms—to inform a whole-person approach to health and wellbeing. This paper aims to provide a theoretical framework for developing an integrative hypothesis in osteopathy, which is based on the enactivist and active inference accounts. We propose that osteopathic care can be reconceptualised under active inference as a unifying framework. Active inference suggests that action-perception cycles operate to minimize uncertainty and optimize an individual’s internal model of the (...) lived world and, crucially, the consequences of their behaviour. We argue that active inference offers an integrative framework for osteopathy, which can evince the mechanisms underlying dyadic and triadic exchanges and osteopathic care outcomes. We propose that this theoretical framework can underpin osteopathic care across the lifespan, from preterm infants to the elderly and those with persistent pain and other physical symptoms. In situations of chronicity, as an ecological niche, the patient-practitioner dyad provides the osteopath and the patient with a set of affordances, i.e., possibilities for action provided by the environment, that through shared intentionally, can promote adaptations and restoration of productive agency. Through a dyadic therapeutic relationship, as they engage with their ecological niche’s affordances—a structured set of affordances shared by agents—osteopath and patient actively construct a shared sense-making narrative and realise a shared generative model of their relation to the niche. In general, touch plays a critical role in developing a robust therapeutic alliance, mental state alignment, and biobehavioural synchrony between patient and practitioner. However, its role is particularly crucial in the fields of neonatology and paediatrics, where it becomes central in regulating allostasis and restoring homeostasis. We argue that from an active inference standpoint, the dyadic shared ecological niche underwrites a robust therapeutic alliance, which is crucial to the effectiveness of osteopathic care. Considerations and implications of this model—to clinical practice and research, both within- and outside osteopathy—are critically discussed. (shrink)

The goal of this paper is to explore a set of epistemological and ontological issues regarding the historical and philosophical role of placebos in the contested history of antidepressants. Starting from an account of the dual nature of the placebo as both an epistemic and a therapeutic tool, and against the background of the heated debates on the efficacy of second-generation antidepressants, I propose two related arguments. First, I argue that placebos as controls played a crucial but paradoxical role in (...) the rise of so-called evidence-based approaches to depression. Second, I discuss how current research on placebo effects puts into question some of the most crucial assumptions of psychiatric technoscience regarding the ontology of affective experiences. Ultimately, this paper aims to probe discussions around placebos, placebo effects, and the status of depression both as a diagnostic category and a lived experience. (shrink)

Physical environmental factors – or ‘artifacts’ – are linked to healthcare outcomes in the field of social psychology. However, the role of artifacts remains rarely examined in the burgeoning discipline of placebo studies. In this paper, we argue that a careful consideration of artifacts – such as provider clothing and office décor – may carry significant potential in eliciting placebo effects in clinical settings. We discuss three potential mechanisms by which artifacts may enhance or diminish placebo (or nocebo) effects: classical (...) conditioning, response expectancy, and mindsets. We propose testable hypotheses and conclude by providing innovative research designs that might help to better advance this novel research agendum. (shrink)

This paper offers theoretical explanations for why “guided touch” or manual touch with verbal communication can be an effective way of treating the body and the mind. The active inference theory suggests that chronic pain and emotional disorders can be attributed to distorted and exaggerated patterns of interoceptive and proprioceptive inference. We propose that the nature of active inference is abductive. As such, to rectify aberrant active inference processes, we should change the “Rule” of abduction, or the “prior beliefs” entailed (...) by a patient’s generative model. This means pre-existing generative models should be replaced with new models. To facilitate such replacement—or updating—the present treatment proposes that we should weaken prior beliefs, especially the one at the top level of hierarchical generative models, thereby altering the sense of agency, and redeploying attention. Then, a new prior belief can be installed through inner communication along with manual touch. The present paper proposes several hypotheses for possible experimental studies. If touch with verbal guidance is proven to be effective, this would demonstrate the relevance of active inference and the implicit prediction model at a behavioral level. Furthermore, it would open new possibilities of employing inner communication interventions, including self-talk training, for a wide range of psychological and physical therapies. (shrink)

BackgroundThere is much overlap among the symptomology of autistic spectrum disorders, obsessive compulsive disorders, and alexithymia, which all typically involve impaired social interactions, repetitive impulsive behaviors, problems with communication, and mental health.AimThis study aimed to identify direct and indirect associations among alexithymia, OCD, cardiac interoception, psychological inflexibility, and self-as-context, with the DV ASD and depression, while controlling for vagal related aging.MethodologyThe data involved electrocardiogram heart rate variability and questionnaire data. In total, 1,089 participant's data of ECG recordings of healthy resting (...) state HRV were recorded and grouped into age categories. In addition to this, another 224 participants completed an online survey that included the following questionnaires: Yale-Brown Obsessive Compulsive Scale ; Toronto Alexithymia Scale 20 ; Acceptance and Action Questionnaire ; Depression, Anxiety, and Stress Scale 21 ; Multi-dimensional Assessment of Interoceptive Awareness Scale ; and the Self-as-Context Scale.ResultsHeart rate variability was shown to decrease with age when controlling for BMI and gender. In the two SEMs produced, it was found that OCD and alexithymia were causally associated with autism and depression indirectly through psychological inflexibility, SAC, and ISen interoception.ConclusionThe results are discussed in relation to the limitations of the DSM with its categorical focus of protocols for syndromes and provide support for more flexible ideographic approaches in diagnosing and treating mental health and autism within the Extended Evolutionary Meta-Model. Graph theory approaches are discussed in their capacity to depict the processes of change potentially even at the level of the relational frame. (shrink)

This Perspective adapts the ViolEx Model, a framework validated in several clinical conditions, to better understand the role of expectations in the recovery and/or maintenance of musculoskeletal pain. Here, particular attention is given to the condition in which dysfunctional expectations are maintained despite no longer being supported by confirmatory evidence. While the ViolEx Model suggests that cognitive immunization strategies are responsible for the maintenance of dysfunctional expectations, we suggest that such phenomenon can also be understood from a Bayesian Brain perspective, (...) according to which the level of precision of the priors is the determinant factor accounting for the extent of priors’ updating. Importantly, this Perspective translates the theory behind these two frameworks into clinical suggestions. Precisely, it is argued that different strategies should be implemented when treating MSK pain patients, depending on the nature of their expectations. (shrink)