Behave: The biology of humans at our best and worst

How can people be so caring and sometimes cruel? What are the evolutionary, genetic, epigenetic, developmental, familial, tribal, community and cultural determinants that allow human beings to be heroic and give their own life for others or be killers and unbelievably cruel.  Stanford biology professor Robert Sapolsky‘s book, Behave: The Biology of Humans at Our Best and Worst, explores what drives human behavior.  It is a remarkable tour de force to explore and explain why we do as we do. Watch his February 6, 2018 lecture at the Jewish Community Center of San Francisco.

  1. behave

Digital addiction*


I felt dismissed and slighted when in the middle of dinner, my friend picked up his phone and quickly glanced at the notification.  The message appeared more important than me.

I had accidentally left my phone at home and the whole day long, I kept reaching for it to check email and social media feeds-I felt emotionally lost.

The host at the dinner party asked us to turn our phone off or leave it at the door.  At first I felt the impulse to check my phone, but during the evening I really connected with the other people.  

As I was running on the trail behind UC Berkeley enjoying the expansive view of the San Francisco Bay, an other idea for this article popped into my head–the importance of taking time to reflect and allow neural regeneration. I rushed back to add those concepts to the article.

When observing university students sitting in the classroom, I see them alone with their heads down looking at their mobile phone. When students enter a classroom, during class breaks, or after class they are continually texting, scrolling, clicking or looking at their smartphone screen instead of engaging with people next to them.  The same habits exist outside the classroom, whether they are leaning against the walls in the hallways, walking between classes, eating pizzas, or standing on the bus, the iNeck posture has become the all too common body position.

We respond automatically to notifications from email, Facebook, Instagram, Snapchat, and Twitter.  Each notification feels so important that we interrupt what we are doing and look at the screen.  The notifications activate neurological pathways that would have been triggered if we perceived a danger signal in our environment (e.g., a carnivore) that would threaten our existence. In addition, it provides updates on our social environment which would be necessary for our group’s survival.

This orienting process is automatic. For example, when you sit next to someone and they open their computer screen – without being prompted and against social etiquette – you automatically glance at their screen. The changing visual stimulation especially in the peripheral vision triggers us to orient to the cause of the visual changes.  In the past these peripheral changes would indicate that there is something going to which we need to pay attention.  It could be the tiger shadowing us or a possible enemy.  Now the ongoing visual display changes hijacks our vigilance that evolved over millions of years for survival. Looking at and being captured by the screen has now become an evolutionary trap (Peper, 2015). A fictional account of the stress generated during  texting when there is not an immediate response is superbly described  by Aziz Ansari & Eric Klinenberg (2015) in their book Modern Romance.

Besides automatically responding to the novel stimuli, our neural reward pathways are activated when we respond to the stimulus, click and scroll and are rewarded by text, videos, or music. The rewards from our scrolling, clicking and surfing are intermittent and creates the internet addiction.

As a result, many people preemptively check their phone or automatically respond to notifications during their waking hours. In social situations, constant phone interruptions cause others to feel slighted and snubbed. In our research students who use their phone the most experience significantly higher levels of isolation/loneliness, depression and anxiety than those who use their phone the least as shown in Figure 1 (Peper et al, 2016).

high and low

Figure 1. Self-reports of isolation, depression and anxiety were significantly higher for students who use their phone the most as compared to those who use their phone the least during socializing.  Reproduced with permission from Peper et al, 2016.

Being on-call and continuously checking the phone also contributes to multitasking which interrupts attention and performance (Jarmon, 2008; Brinols & Rajesh, 2014). Many students no longer focus on one task at hand; instead, they are multitasking and interrupt their tasks by by responding to social media, listening to music or surfing the web (Swingle, 2016Clement and Miles, 2018).   In our recent survey of 135 university students, almost all report that they multitask even though it would be better to focus on the required task and shift focus after the task was done as is shown in Figure 2 (Peper et al, 2014).


Figure 2. Self-report of multitasking. Reproduced with permission from Peper et al, 2014.

How come we have become so addicted that we feel the urgency to check our phones day and night even if when there are no notifications?

The screen is the first focus of attention when we wake up and the last one before sleep. We cannot even wait to finish a meal or talk to a friend before checking the phone for possible updates.  For this addictive behavior, we can thank the major tech companies who have hired the smartest and brightest engineers, programmers and scientists to develop software and hardware to capture our attentions and conditions us to be addicted to increase corporate profit: more eyeballs, more clicks, more money. For a detailed analysis of how Tech companies created our addiction, see the superb article by Michael Schulson (2018), If the internet is addictive, why don’t we regulate it?

Do not place the blame on the child or adult who claim they do not have self-control.  The addiction was predominantly created by tech companies in their quest to capture market share by exploiting our natural evolutionary survival responses to orient and attend to a change in our visual and auditory world which has become an evolutionary trap. By providing intermittent reinforcers, the addiction is quickly established and challenging to overcome (Alter, 2017).  The addiction is similar to the opioid addiction which was created by pharmaceutical companies in their on-going quest to increase profits. Just as opioid addiction leads to long term harm, I wonder about the long term harm of internet addiction. It may be worse than the opioid addiction because it reduces actual social connections and emotional regulation, increases distractibility and attention deficit and, and decreases self-initiative (proactive versus reactive behavior) which may result in compromised health and well-being.

Being plugged-in and connected limits the time for reflection and regeneration. This un-programed time allows new ideas and concepts to emerge, provides time to assess your own and other people’s actions from a distant perspective.  It offers the pause that refreshes and time for neural regeneration. Our nervous system, just like our muscular system, grow when there is enough time to regenerate after being stressed. Ongoing stress or stimulation without time to regenerate leads to illness and neural death.  The phenomena can be seen in the development of rat brains.

Neuroanatomist Professor Marion Diamond showed that rats who were brought up in an impoverished environment and had very little stimulation had a thinner cortex and less dendritic connections than rats brought up in an enriched environment (Rosenzweig, 1966; Diamond et al, 1975).  More importantly, an excessively enriched environment was associated to a reduction of neurogenesis and synaptic plasticity (Joels et al, 2004). The more hours of television a child between age 1 and 3 watched was directly correlated with associated attentional problems at age 7 (Christakis et al, 2004). This suggests that excessive stimulation during brain development may be harmful.  Thus,  from a biological perspective health is the alternation between activity and regeneration. If the brain is not allowed enough time to be off-line and regenerate, neural degeneration most likely will occur.

Mobilize your health and disconnect to allow regeneration. Take charge of your addiction,  regain social connections, and develop proactive attention.

  1. Recognize that you have been manipulated into addiction by the tech companies which have covertly conditioned you to react to notifications and creating the desire (addiction) to check for updates.
  2. Become proactive by limiting interruptions when you work and play.

Recommended readings

Alter, A. (2017). Irresistible: The Rise of Addictive Technology and the Business of Keeping Us Hooked. New York: Penguin Press. Explores in detail how and why we have become addicted and offers strategies how we can harness the addiction for the good.

Clement, J. & Miles, M. (2018). Screen schooled-Two veteran teachers expose how technology overuse is making our kids dumber. Chicago: Chicago Review Press. A superb analysis how screen saturation at home and school has created a wide range of cognitive and social deficits in our young people.

Foer, F. (2017). World without mind-The existential threat of big tech. New York: Penguin Press. A passionate informed case that the great tech companies are robbing us of our individuality, humanity, our values and how to deal with complexity. It offers strategies to take back your autonomy and mind.

Swingle, M. (2016). i-Minds: How Cell Phones, Computers, Gaming, and Social Media are Changing our Brains, our Behavior, and the Evolution of our Species. Gabriola Island, BC
Canada: New Society Publishers. Based upon 18 years of clinical observations this book describes in detail how the digital revolution is change our brains and offers constructive strategies how to use the digital tool constructively.

* Adapted from Peper, E. & Harvey, R. (2018). Digital addiction: increased loneliness, depression, and anxiety. NeuroRegulation. 5(1),3–8doi:10.15540/nr.5.1.3


Alter, A. (2017). Irresistible: The Rise of Addictive Technology and the Business of Keeping Us Hooked. New York: Penguin Press. Explores in detail how and why we have become addicted and offers strategies how we can harness the addiction for the good.

Ansari, A. & Klinenberg, E. (2015). Modern Romance 
by Penguin Press: New York.

Brinols, A.B. & Rajesh, R. (2014). Multitasking with smartphones in the college classroom. Business and Professional Communication Quarterly, 77(1), 89–95.

Christakis, D.A., Zimmerman, F.J., DiGiuseppe, D.L., &  McCarty, C.A. (2004). Early Television Exposure and Subsequent Attentional Problems in Children. Pediatrics. 113(4).

Clement, J. & Miles, M. (2018). Screen schooled-Two veteran teachers expose how technology overuse is making our kids dumber. Chicago: Chicago Review Press.

Diamond, M. C., Lindner, B., Johnson, R., Bennett, E. L., & Rosenzweig, M. R. (1975). Difference in occipital cortical synapses from environmentally enriched, impoverished, and standard colony rats. Journal of Neuroscience Research, 1(2), 109-119.

Jarmon, A. L. (2008). Multitasking: Helpful or harmful? Student Lawyer, 36(8), 31-35.

Joels, M.., Karst, H., Alfarez, D.,  Heine, V.M., Qin, Y.,  van Riel, E., Verkuyl, M., Lucassen, P.J., & . Krugers, H.J. (2004). Effects of chronic stress on structure and cell function in rat hippocampus and hypothalamus. Stress, 7(4), 221-231.

Peper, E., Harvey, R., Lin, E., Lau, S., Mitose, J., & Rogers. (2014). Cellphone and multitasking survey of college students.  Unpublished manuscript. San Francisco State University.

Peper, E. (2015). Evolutionary/environmental traps create illness: Be aware of commercialized stimuli. Psychophysiology Today-The E Magazine for Mind-Body Medicine. 10(1), 9-11.

Peper, E., Silva, L.M., & Grasham, G. (2016). Cell phone use by university students. Unpublished manuscript, San Francisco State University.

Rosenzweig, M. R. (1966). Environmental complexity, cerebral change, and behavior. American Psychologist, 21(4), 321-332.

Shulson, M. (2018). If the internet is addictive, why don’t we regulate it?Aeon.

Swingle, M. (2016). i-Minds: How Cell Phones, Computers, Gaming, and Social Media are Changing our Brains, our Behavior, and the Evolution of our Species. Gabriola Island, BC
Canada: New Society Publishers.



Improve your health: Lower your carbs

skinny to faat

How come there  is no disease caused by the absence of carbohydrates?  This simple observation suggests that carbohydrates are not necessary for health and are not an essential food in our evolutionary history.  This is different from vitamin C or other essential nutrients whose absence will cause scurvy and eventually death.

From an evolutionary perspective, simple carbohydrates, especially sugars and high-fructose corn syrup, are significant contributing factors to the increasing epidemic of obesity, type 2 diabetes, metabolic syndrome,  coronary heart disease and  many  autoimmune disorders. The recommended nutritional guideline of the last forty years to reduce fats and increase carbohydrates were not based upon good science but on ideology influenced by agribusiness and the sugar industry (La Berge,  2008). The recommendations were WRONG AND HARMFUL (Taubes, 2016; see also:  It may explains why the obesity epidemic is not caused by eating or drinking too many calories but the eating the wrong type of calories; namely,  those found in simple carbohydrates and overly processed foods.  The increase in obesity appears highly correlated with the US low-fat diet recommendations published in 1977 as shown in figure 1.

obesity in USA and low fat dietaFigure 1. Increase in U.S. obesity begins after the publication of the U.S. recommendations to eat a low-fat diet. Reproduced from National Center for Health Statistics (US). Health, United States, 2008: With Special Feature on the Health of Young Adults. Hyattsville (MD): National Center for Health Statistics (US); 2009 Mar. Chartbook

The harmful effects of the simple high carbohydrate diet  amplified with a decrease in physical activity interacts with your genetics.  People,  with a family risk factors of metabolic syndrome (type 2 diabetes) can improve their health by eating a low carbohydrate diet with lots of vegetables, fruit and fats.

Watch the superb video lectures by Professor Timothy Noakes, an emeritus professor of exercise and sports science at the University of Cape Town and by Gary Taubes, science writer and author of The case against sugar.  It may shift your perspective and improve your health.


La Berge, A. F. (2008). How the ideology of low fat conquered America.  Journal of the History of Medicine and Allied Sciences, Volume 63, Issue 2, 1 April 2008, Pages 139–177,

National Center for Health Statistics (US). Health, United States, 2008: With Special Feature on the Health of Young Adults. Hyattsville (MD): National Center for Health Statistics (US); 2009 Mar. Chartbook

Taubes, G. (2016). The Case Against Sugar. Portobello Books. ISBN 978-0-307-70164-0

Happy New Year: Explore the positive

As the New Year begins, I wish you health, happiness and the courage to follow your dreams. Even though we may face challenges, they are also the gateway to new opportunities. Within each person there are unknown potentials which are so often limited by our beliefs.  Enjoy the video that points out there is nothing more powerful than a human being with a dream. Best wishes for the New Year.



How effective is treatment? The importance of active placebos

Adapted by Erik Peper and Richard Harvey from: Peper, E. & Harvey, R. (2017). The fallacy of the placebo-controlled clinical trials: Are positive outcomes the result of “indirect” treatment effects? NeuroRegulation, 4(3–4), 102–113.

How come some drugs or medical procedures are initially acclaimed to be beneficial and later ineffective or harmful and withdrawn from the market? 

 How come some patients with a cancer diagnosis experience symptom remission after receiving a placebo medication?  Take the case of Mr. Wright. Several decades ago Dr. Klopher (1957) described Mr. Wright as a patient who had a generalized and far advanced malignancy in the form of a lymphosarcoma with an estimated life expectancy of less than two weeks. Following the diagnosis Mr. Wright read a newspaper article about a promising experimental cancer medication called Krebiozen and requested that he receive the latest treatment.  Soon after receiving the drug, Mr. Wright had a complete remission of cancer symptoms with no signs of the deadly tumor. For over two months after receiving the new promising drug, Krebiozen, Mr. Wright engaged in a normal life and was even able to fly his own plane at 12,000 feet.  After a promising introduction to the medication, Mr. Wright subsequently read another newspaper article which proved the new medication to be a useless, inert preparation.  Confused and demoralized, the results of the wonder drug did not last and his symptoms returned. When the final AMA announcement was published “Nationwide tests show Krebiozen to be a worthless drug in treatment of cancer,” his symptoms became acute and he died within two days (Klopher, 1957).

The term placebo loosely translates as ‘I shall please you’ can be contrasted with the term nocebo which loosely translates as ‘I shall harm you’ when referring to exposure to a sham medication, treatment or procedure that results a positive outcome (placebo response), or a negative outcome (nocebo response), respectively.  The responses a person has reflect a complex interaction between many processes.  For example, when studying a placebo or nocebo response we measure internal psychological processes, measured in terms of a person’s self-reported attitudes, beliefs, cognitions and emotions; behavioral processes, measured overtly by observations of a person’s actions; and, physiological processes, measured more or less directly with instruments such as heart rate monitors, or biochemical analyses.  Most relevant is that a person’s beliefs about the placebo (or nocebo) medication, treatment or procedure leads to predictable positive (or negative) behaviors and physiological benefits or harms.

The case of Mr. Wright illustrates that we may underestimate the positive power of the placebo or, the negative power of the nocebo, where Mr. Wright’s belief about the medication’s benefits first interacted in a positive way (placebo) with his behaviors (e.g. engaging in daily activities including flying an airplane) as well as his physiology (e.g. cancer remission) and unfortunately later, in a negative way (nocebo) interacting with his physiology (e.g. cancer return) contributing to his death.

The placebo response can be very powerful and healing.  For example, watch the very dramatic demonstration of how the placebo response can be optimized in Derren Brown’s BBC video Fear and Faith Placebo

Placebo and nocebo effects are found in all therapeutic transactions when the communications between therapist and patient reflect embedded beliefs about the treatment.  For example, patients have faith in clinician’s knowledge and belief that a prescribed medication is going to be effective at treating their symptoms, which then reinforces the patient’s belief in the medication, increasing indirect, embedded placebo effects, above and beyond any direct effects from the medication. The indirect effects of placebo responses have been most studied with medications; however, placebo effects are also studied in non-drug therapies. The research on placebo effects has demonstrated time and time again that when patients expect that the drug, surgery, or other therapeutic technique to be beneficial, then the patients tend to benefit more from the treatment.

The expectancy that the treatment will be effective at reducing symptoms is overtly, and covertly communicated by the health care professional during patient interactions, as well as by drug companies through direct to consumer advertising, and social media.  The implied message is that the drug or procedure will improve symptoms, recovery or improve quality of life. On the other hand, if you do not do take the drug or do the procedure, your health will be compromised. For example, if you have high cholesterol, then take a statin drug to prevent the consequences of high cholesterol such as a heart attack or stroke.  The implied message is that if you do not take it, you will die significantly sooner.  Statins lower the risk for heart attacks; however, the benefits may be over stated. For people without prior heart disease, 60 people will have to take statins for 5 years to prevent 1 heart attack and 268 people to prevent 1 stroke. During the same time period 1 in 10 will experience muscle damage and 1 in 50 develop diabetes (theNNT, 2017 November).

If placebo and nocebo can have  significant effects on medical outcome, how do you know if the treatment benefits are due to the direct effects of a drug or procedure or due to any indirect placebo effects or a combination of both?

The randomized controlled trial (RCT) is considered the gold standard method to determine the effectiveness of a drug or procedure. The ideal study would be a double blind, randomized, placebo controlled clinical trial in which neither the practitioner nor the patient would know who is getting what condition.  For example, blinding implies the placebo group would receive a pill that appears identical to a ‘real’ pill, except the placebo has pharmacological ingredients.  Similarly, a patient may receive an ‘exploratory’ surgery in which anesthesia is given and the skin is cut however the no further actual internal surgery occurs because the surgeon determined further internal surgery was unnecessary. Although, it is not possible to perform a double blind surgery study, the patient may be totally unaware whether an internal surgery had occurred.

Peper and Harvey (2017) point out that the positive findings of an ‘effective’ treatment are not always the results of the direct effects of medications and may be more attributable to indirect placebo responses.  For example, patients may attribute the ‘effectiveness’ of the treatment to their experience of ‘non-directed’ treatment side effects that include: the post-surgical discomfort which signals to the patient that the procedure was successful, or a dry mouth and constipation that were caused by the antidepressant medication, which signals to the person that the trial medication or procedure-related medication is working (Bell, Rear, Cunningham, Dawnay, & Yellon, 2014; Stewart-Williams & Podd, 2004).

Just imagine the how pain can evoke totally different reactions.  If you recently had a heart attack and then later experienced pain and cramping in the chest, you automatically may feel terrified as you could interpret the pain as another heart attack. The fear response to the pain may increase pathology and inhibit healing (a nocebo response).  On the other hand, after bypass surgery, you may also experience severe pain when you move your chest. In this case, you interpret the pain as a sign that the bypass surgery was successful, which then reduces fear and reinforces the belief that you have survived a life threatening situation and will continue healing (placebo response).

Many research studies employ a placebo control, however what is less typical is a double-blind study using an ‘active’ placebo (Enck, Bingel, Schedlowski, & Rief, 2013). Less than 0.5% of all placebo studies include an active placebo group. (Shader, 2017; Jensen et al, 2017).

Unfortunately, a typical ‘placebo controlled’ study design is problematic for distinguishing the direct from any indirect (covert) placebo effects that occur within the study as shown in Figure 1.

Passive placeboFigure 1. Normal (passive) placebo control group controls and experimental group.  What is not assessed are placebo benefits induced by the medication/treatment induced side effects.

With a passive placebo, there is no way to know if the observed benefits are from the medication/medical procedure, or from the placebo/self-healing response triggered by the medication/medical procedure (or both combined, or neither the placebo or medical procedure). The best way to know if the treatment is actually beneficial is to use an ‘active’ placebo instead of a passive placebo.

An active placebo builds on a patient’s attributions about a medication or medical procedure.  For example, a patient may be told by a clinician that feeling any side effects such as insomnia, a racing heart or, experiencing a warm flushing feeling will let them know the medication is working, so the patient becomes conditioned to expect the medication is working when they feel or experience side effects.  Whereas a passive (inert) placebo such as a sugar pill will have effects that are extremely subtly felt or experienced, an active placebo will have effects that are more overtly felt or experienced.   Examples of active placebos include administering low doses of caffeine or niacin that have effects which may be felt internally however which do not have the same effects as the medication.  When a patient is told they may have side effects from the medication that include felt changes in heart rate or a flushing feeling, the patient attributes the changes they feel to a medication they believe will bring about benefits, even though the changes are rightfully attributed to the caffeine or niacin in the active placebo.

An active placebo triggers observed and felt body changes which do not affect the actual illness. For surgical procedures, an ‘active’ placebo control would be a sham/mock surgery in which the patient would undergo the same medical procedure (e.g. external surgery incision) without continuing some internal surgical procedure (Jonas et al, 2015).  In numerous cases of accepted surgery, such as the Vineberg procedure (Vineburg & Miller, 1951) for angina, or arthroscopic knee surgery for treating osteoarthritis, the clinical benefits of a sham/mock surgery were just as successful as the actual surgery. Similar studies suggest the clinical benefits were solely (or primarily) due directly to the placebo response (Beecher, 1961; Cobb et al, 1959; Moseley et al, 2002).

To persuasively demonstrate that a treatment or therapeutic procedure is effective it should incorporate a study design using an active placebo arm as shown in Figure 2.Active placebo newFigure 2. Active placebo control group controls for the normal placebo benefits plus those placebo benefits induced by the medication/treatment induced side effects.

Some treatments may be less effective then claimed because they were not compared to an active placebo, which could be one of the reasons why so many medical and psychological studies cannot be replicated.  The absence of ‘active’ placebo controls may also be a factor explaining why some respected authorities have expressed some doubt about published scientific medical research results.  Following are two quotes that illustrate such skepticism.

“Much of the scientific literature, perhaps half, may simply be untrue.”  —Richard Horton, editor-in-chief of the Lancet (Horton, 2015).

“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of the New England Journal of Medicine”  Dr. Marcia Angell, longtime Editor in Chief of the New England Medical Journal (Angell, 2009).

There are a variety of questions to ask before agreeing on a procedure or before taking medication

A quick way to ask whether a medication or medical treatment effectiveness is the result of placebo components is to ask the following questions:

  1. Have there been successful self-care or behavioral approaches beyond surgical or pharmaceutical treatments that have demonstrated effectiveness? When successful treatments are reported, then questions are raised whether pharmaceutical or surgical outcomes are also attributable to the result of placebo effects. On the other hand, if there a no successful self-care approaches, then the benefits may be more due to the direct therapeutic effect of a surgical procedure or medication.
  2. Has the procedure been compared to an active placebo control? If not, then to what extent it is possible that the results of the surgical or pharmaceutical therapy could be attributed to a placebo response instead of directly to the medication or surgery?
  3. What are the long term benefits and complication rates of the medication, treatment or procedure? When benefits are low and risks of the procedure are high, explore the risks associated with ‘watchful waiting’ (Colloca, Pine, Ernst, Miller & Grillon, 2016; Thomas et al, 2014; Taleb, 2012).

Unfortunately, most clinical studies that includes pharmaceuticals and/or surgery do not test their medication, surgery against an ‘active’ placebo.  Whenever possible, enquire whether an active placebo was used to determine the degree of effectiveness of the proposed treatment or procedure.  Fortunately, the design of ‘active’ placebo-controlled studies is very possible for anyone interested in comparing the effectiveness of medications, treatments and procedures in various settings, from hospitals and clinics to university classrooms and individual homes.

In summary, the benefits of the treatment must significantly outweigh any risks of negative treatment side effects.  Short-term treatment benefits need to be balanced by any long-term benefits.  Unfortunately, short-term benefits may lead to significant, long-term harm such as in the use of some medications (e.g. sleep medications, opioid pain killers) that result in chronic dependency and which lead to a significant increase in morbidity and mortality of many kinds. We suggest that more medications and other procedures are tested against an active placebo to investigate whether the medication or procedure is actually effective.

For a detailed analysis and discussion of placebo and the importance of active placebo see our article, Peper, E. & Harvey, R. (2017). The fallacy of the placebo-controlled clinical trials: Are positive outcomes the result of “indirect” treatment effects? NeuroRegulation, 4(3–4), 102–113.


Angell M. Drug companies and doctors: A story of corruption. January 15, 2009. The New York Review of Books 56. Available: Accessed 24, November, 2016.

Beecher, H. K. (1961). Surgery as placebo: A quantitative study ofbias. JAMA, 176(13), 1102–1107.

Bell, R. M., Rear, R., Cunningham, J., Dawnay, A., & Yellon, D. M. (2014). Effect of remote ischaemic conditioning on contrast-induced nephropathy in patients undergoing elective coronary angiography (ERICCIN): rationale and study design of a randomised single-centre, double-blind placebo-controlled trial. Clinical Research in Cardiology, 103(3), 203-209.

Cobb, L. A., Thomas, G. I., Dillard, D. H., Merendino, K. A., & Bruce, R. A. (1959). An evaluation of internal-mammary-artery ligation by a double-blind technic. New England Journal of Medicine, 260(22), 1115–1118.

Colloca, L., Pine, D. S., Ernst, M., Miller, F. G., & Grillon, C. (2016). Vasopressin boosts placebo analgesic effects in women: A randomized trial. Biological Psychiatry, 79(10), 794–802.

Derren Brown’s BBC video Fear and Faith Placebo

 Enck, P., Bingel, U., Schedlowski, M., & Rief, W. (2013). The placebo response in medicine: minimize, maximize or personalize?. Nature reviews Drug discovery, 12(3), 191-204.

Horton, R. (2015). Offline: What is medicine’s 5 sigma. The Lancet, 385(9976), 1380.

Jensen, J. S., Bielefeldt, A. Ø., & Hróbjartsson, A. (2017). Active placebo control groups of pharmacological interventions were rarely used but merited serious consideration: A methodological overview. Journal of Clinical Epidemiology.

Jonas, W. B., Crawford, C., Colloca, L., Kaptchuk, T. J., Moseley, B., Miller, F. G., & Meissner, K. (2015). To what extent are surgery and invasive procedures effective beyond a placebo response? A systematic review with meta-analysis of randomised, sham controlled trials. BMJ open, 5(12), e009655.

Klopfer, B., (1957). Psychological Variables in Human Cancer, Journal of Projective Techniques, 21(4), 331–340.

Moseley, J. B., O’Malley, K., Petersen, N. J., Menke, T. J., Brody, B. A., Kuykendall, D. H., … Wray, N. P. (2002). A controlled trial of arthroscopic surgery for osteoarthritis of the knee. The New England Journal of Medicine. 347(2), 81–88. /NEJMoa013259

Peper, E. & Harvey, R. (2017). The fallacy of the placebo-controlled clinical trials: Are positive outcomes the result of “indirect” treatment effects? NeuroRegulation, 4(3–4), 102–113.

Shader, R. I. (2017). Placebos, Active Placebos, and Clinical Trials. Clinical Therapeutics, 39(3), 451–454.

Stewart-Williams, S., & Podd, J. (2004). The placebo effect: dissolving the expectancy versus conditioning debate. Psychological bulletin, 130(2), 324.

Taleb, N. N. (2012). Antifragile: Things that gain from disorder. Random House.

TheNNT (2017, November).

Thomas, R., Williams, M., Sharma, H., Chaudry, A., & Bellamy, P. (2014). A double-blind, placebo-controlled randomised trial evaluating the effect of a polyphenol-rich whole food supplement on PSA progression in men with prostate cancer—the UK NCRN Pomi-T study. Prostate Cancer and Prostatic Diseases, 17(2), 180–186.

Vineberg, A., & Miller, G. (1951). Treatment of coronary insufficiency. Canadian Medical Association Journal, 64(3), 204.




Overcoming obstacles

In a world with so much violence, inequalities and overwhelming negative news, it is easy to feel discouraged and forget that people can overcome trauma. Take charge of the news and images that surround us since the sounds and images impact our brain.  Instead of watching disheartening and violent news before going to sleep, inspire yourself by watching the following two videos.

Muniba Mazari who at age 21 sustained spinal cord damage which left her paraplegic. She is an activist, motivational speaker and television host.

Mandy Harvey who at age nineteen lost her hearing and is an outstanding American pop singer and songwriter. Even though she is deaf, she received Simon’s Golden Buzzer in America’s Got Talent 2017 while singing her original song.

Posture and mood: implications and applications to health and therapy

This blog has been reprinted from: Peper, E., Lin, I-M, & Harvey, R. (2017). Posture and mood: Implications and applications to therapy. Biofeedback.35(2), 42-48.

Slouched posture is very common and tends to increase access to helpless, hopeless, powerless and depressive thoughts as well as increased head, neck and shoulder pain. Described are five educational and clinical strategies that therapists can incorporate in their practice to encourage an upright/erect posture. These include practices to experience the negative effects of a collapsed posture as compared to an erect posture, watching YouTube video to enhance motivation, electromyography to demonstrate the effect of posture on muscle activity, ergonomic suggestions to optimize posture, the use of a wearable posture biofeedback device, and strategies to keep looking upward. When clients implement these changes, they report a more positive outlook and reduced neck and shoulder discomfort.


Most people slouch without awareness when looking at their cellphone, tablet, or the computer screen (Guan et al., 2016) as shown in Figure 1. Many clients in psychotherapy and in biofeedback or neurofeedback training experience concurrent rumination and depressive thoughts with their physical symptoms. In most therapeutic sessions, clients sit in a comfortable chair, which automatically creates a posterior pelvic tilt and encourages the spine to curve so that the client sits in a slouched position. While at home, they sit on an easy chair or couch, which lets them slouch as they watch TV or surf the web.Figure 1 three collapsed positions

Figure 1. (A). Employee working on his laptop. (B). Boy with ADHD being trained with neurofeedback in a clinic. (C). Student looking at cell phone. When people slouch and look at the screen, they tend to slouch and scrunch their neck.

In many cases, the collapsed position also causes people to scrunch their necks, which puts pressure on their necks that may contribute to developing headache or becoming exhausted. Repetitive strain on the neck and cervical spine may trigger a cervical neuromuscular syndrome that involves chronic neck pain, autonomic imbalance and concomitant depression and anxiety (Matsui & Fujimoto, 2011), and may contribute to vertebrobasilar insufficiency –a reduction in the blood supply to the hindbrain through the left and right vertebral arteries and basilar arteries (Kerry, Taylor, Mitchell, McCarthy, & Brew, 2008). From a biomechanical perspective, slouching also places more stress is on the cervical spine, as shown in Figure 2. When the neck compression is relieved, the symptoms decrease (Matsui & Fujimoto, 2011).

Figure 2 head collapseFigure 2. The more the head tilts forward, the more stress is placed on the cervical spine. Reproduced by permission from: Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology International, 25, 277–279.

Most people are totally unaware of slouching positions and postures until they experience neck, shoulder, and/or back discomfort. Neither clients nor therapists are typically aware that slouching may decrease energy levels and increase the prevalence of negative (hopeless, helpless, powerless, or defeated) memories and thoughts (Peper & Lin, 2012; Peper et al, 2017)

Recommendations for posture awareness and training in treatment/education 

The first step in biofeedback training and therapy is to systematically increase awareness and training of posture before attempting further bio/neurofeedback training and/or cognitive behavior therapy. If the client is sitting in a collapsed position in therapy, then it will be much more difficult for them to access positive thoughts, which interferes with further training and effective therapy. For example, research by Tsai, Peper, & Lin (2016) showed that engaging in positive thinking while slouched requires greater mental effort then when sitting erect. Sitting erect and tall contributes to elevated mood and positive thinking. An upright posture supports positive outcomes that may be akin to the beneficial effects of exercise for the treatment of depression (Schuch, Vancampfort, Richards, Rosenbaum, Ward, & Stubbs., 2016).

Most people know that posture affects health; however, they are unaware of how rapidly a slouching posture can impact their physical and mental health. We recommend the following educational and clinical strategies to teach this awareness.

  1. Practicing activities that raise awareness about a collapsed posture as compared to an erect posture

Guide clients through the practices so that they experience how posture can affect memory recall, physical strength, energy level, and possible triggering of headaches.

A. The effect of collapsed and erect posture on memory recall. Participants reported that it is much easier evoke powerless, hopeless, helpless, and defeated memories when sitting in a collapsed position than when sitting upright. Guide the client through the procedure described in the article, How posture affects memory recall and mood (Peper, Lin, Harvey, and Perez, 2017) and in the blog Posture affects memory recall and mood.

B. The effects of collapsed and erect posture on perceived physical strength. Participants experience much more difficulty in resisting downward pressure at the wrist of an outstretched arm when slouched rather than upright. Guide the client through the exercise described in the article, Increase strength and mood with posture (Peper, Booiman, Lin, & Harvey, 2016) and the blog, Increase strength and mood with posture.

C. The effect of slouching versus skipping on perceived energy levels. Participants experience a significant increase in subjective energy after skipping than walking slouched. Guide the client through the exercises as described in the article, Increase or decrease depressionHow body postures influence your energy level (Peper & Lin, 2012).

D. The effect of neck compression to evoke head pressure and headache sensations. In our unpublished study with students and workshop participants, almost all participants who are asked to bring their head forward, then tilt the chin up and at the same time compress the neck (scrunching the neck), report that within thirty seconds they feel a pressure building up in the back of the head or the beginning of a headache. To their surprise, it may take up to 5 to 20 minutes for the discomfort to disappear. Practicing similar awareness activities can be a useful demonstration for clients with dizziness or headaches to experience how posture can increase their symptoms.

  1. Watching a Youtube video to enhance motivation.

Have clients watch Professor Amy Cuddy’s 2012 TED (Technology, Entertainment, and Design) Talk, Your body language shape who you are, which describes the hormonal changes that occur when adapting a upright power versus collapsed defeated posture.

  1. Electromyographic (EMG) feedback to demonstrate how posture affects muscle activity.

Record EMG from muscles such as around the cervical spine, trapezius, frontalis, and masseters or beneath the chin (submental lead) to demonstrate that having the head is forward and/or the neck compressed will increase EMG activity, as shown in Figure 3.

Figure 3 Head position

Figure 3. Electromyographic recording of the muscle under the chin while alternating between bringing the head forward or holding it back, feeling erect and tall.

The client can then learn awareness of the head and neck position. For example, one client with severe concussion experienced significant increase in head pressure and dizziness when she slouched or looked at a computer screen as well as feeling she would never get better. She then practiced the exercise of alternating her awareness by bringing her head forward and then back, and then bringing her neck back while her chin was down, thereby elongating the neck while she continued to breathe. With her head forward, she would feel her molars touching and with her neck back she felt an increase in space between the molars. When she elongated her neck in an erect position, she felt the pressure draining out of her head and her dizziness and tinnitus significantly decrease.

  1. Assessing ergonomics to optimize posture.

Change the seated posture of both the therapist and the client during treatment and training. Although people may be aware of their posture, it is much easier to change the external environment so that they automatically sit in a more erect power posture. Possible options include:

A. Seat insert or cushions. Sit in upright chairs that encourage an anterior pelvic tilt by having the seat pan slightly lower in the front than in the back or using a seat insert to facilitate a more erect posture (Schwanbeck, Peper, Booiman, Harvey, & Lin, 2015) as shown in Figure 4.

Figure 4 backjoy insert sitting with spine markers

Figure 4. An example of how posture can be impacted covertly when one sits on a seat insert that rotates the pelvis anteriorly (The seat insert shown in the diagram and used in research  is produced by BackJoy™).

B. Back cushion. Place a small pillow or rolled up towel at the kidney level so that the spine is slight arched, instead of sitting collapsed, as shown in Figure 5.

Figure 5 sitting with and without pillowFigure 5. An example of how a small pillow, placed between the back of the chair and the lower back, changes posture from collapsed to erect.

C. Check ergonomic and work site computer use to ensure that the client can sit upright while working at the computer. For some, that means checking their vision if they tend to crane forward and crunch their neck to read the text. For those who work on laptops, it means using either an external keyboard, a monitor, or a laptop stand so the screen is at eye level, as shown in Figure 6.

Figure 6 laptop ergonomicsFigure 6. Posture is collapsed when working on a laptop and can be improved by using an external keyboard and monitor. Reproduced by permission from: Bakker Elkhuizen. (n.d.). Office employees are like professional athletes! (2017).

  1. Wearable posture biofeedback training device

The wearable biofeedback device, UpRight™, consists of a small sensor placed on the spine and works as an app on the cell phone. After calibration the erect and slouched positions, the posture device gives vibratory feedback each time the participant slouches, as shown in Figure 7.Figure 7 UpRight collapse erect

Figure 7. Illustration of a posture feedback device, UpRight™. It provides vibratory feedback to the wearer to indicate that they are beginning to slouch.

Clinically, we have observed that clients can learn to identify conditions that are associated with slouching, such as feeling tired, thinking depressive/hopeless thoughts or other situations that evoke slouching. When people wear a posture feedback device during the day, they rapidly become aware of these subjective experiences whenever they slouch. The feedback reminds them to sit in an erect position, and they subsequently report an improvement in health (Colombo et al., 2017). For example, a 26-year-old man who works more than 8 hours a day on computer reported, “I have an improved awareness of my posture throughout my day. I also notice that I had less back pain at the end of the day.”

  1. Integrating posture awareness and position changes throughout the day

After clients have become aware of their posture, additional training included having them observe their posture as well and negative changes in mood, energy level or tension in their neck and head. When they become aware of these changes, they use it as a cue to slightly arch their back and look upward. If possible have the clients look outside at the tops of trees and notice details such as how the leaves and branches move. Looking at the details interrupts any ongoing rumination. At the same time, have them think of an uplifting positive memory. Then have them take another breath, wiggling, and return to the task at hand. Recommend to clients to go outside during breaks and lunchtime to look upward at the trees, the hills, or the clouds. Each time one is distracted, return to appreciate the natural patterns. This mental break concludes by reminding oneself that humans are like trees.

Trees are rooted in the earth and reach upward to the light. Despite the trauma of being buffeted by the storms, they continue to reach upward. Similarly, clouds reflect the natural beauty of the world, and are often visible in the densest city environment. The upward movement reflects our intrinsic resilience and growth.       –Erik Peper

Have clients place family photos and art slightly higher on the wall at home so they automatically look upward to see the pictures. A similar strategy can be employed in the office, using art to evoke positive feelings. When clients integrate an erect posture into their daily lives, they experience a more positive outlook and reduced neck and shoulder discomfort.

Compliance with Ethical Standards:

Conflict of Interest: Author Erik Peper has received donations of 15 UpRight posture feedback devices from UpRight ( and 12 BackJoy seat inserts from Backjoy ( for use in research. Co-authors I-Mei Lin and Richard Harvey declare that they have no conflict of interest.

This report evaluated a convenience sample of a student classroom activity related to posture and the information was anonymous collected. As an evaluation of a classroom activity, this report of findings was exempted from Institutional Review Board oversight


Bakker Elkhuizen. (n.d.). Office employees are like professional athletes! (2017). Retrieved from

Colombo, S., Joy, M., Mason, L., Peper, E., Harvey, R., & Booiman, A. Posture Change Feedback Training and its Effect on Health. Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback.42(2), 147.

Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at:

Guan, X., Fan, G., Chen, Z., Zeng, Y., Zhang, H., Hu, A., … He, S. (2016). Gender difference in mobile phone use and the impact of digital device exposure on neck posture. Ergonomics59(11), 1453–1461.

Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology International, 25, 277-279

Kerry, R., Taylor, A.J., Mitchell, J., McCarthy, C., & Brew, J. (2008). Manual therapy and cervical arterial dysfunction, directions for the future: A clinical perspective. Journal of Manual & Manipulative Therapy, 16(1), 39–48.

Matsui, T. & Fujimoto, T. (2011). Treatment for depression with chronic neck pain completely cured in 94.2% of patients following neck muscle treatment. Neuroscience & Medicine, 2, 71­77.

Peper, E., Booiman, A., Lin, I. M., & Harvey, R. (2016). Increase strength and mood with posture. Biofeedback. 44(2), 66–72.

Peper, E. & Lin, I. M. (2012). Increase or decrease depression-How body postures influence your energy level. Biofeedback, 40 (3), 126-130.

Peper, E., Lin, I. M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood. Biofeedback, (45 (2), 36-41.

Schwanbeck, R., Peper, E., Booiman, A., Harvey, R., & Lin, I. M. (2015). Posture Changes with a Seat Insert: Changes in strength and not EMG. Applied Psychophysiology and Biofeedback, 40, 128–129.

Schuch, F. B., Vancampfort, D., Richards, J., Rosenbaum, S., Ward, P. B., & Stubbs, B. (2016). Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. Journal of Psychiatric Research77, 42–51.

Tsai, H. Y., Peper, E., & Lin, I. M. (2016). EEG patterns under positive/negative body postures and emotion recall tasks. NeuroRegulation, 3(1), 23–27.

We thank Frank Andrasik for his constructive comments.