Skip to main content

Central inhibition and placebo analgesia

Most neuroscientists measure neuronal activity in the brain to predict or explore the contribution of neurons to physiological/pathological functions of the brain. For example, if an increase in neuronal activity is detected in one brain region by peripheral noxious stimuli, we call this area the pain region or pain matrix. In the case of activity detected during conscious processes, such as placebo treatment, we label these regions as responsible for the placebo treatment. Due to limited access to the conscious brain and the reductionist nature of most modern neuroscience, we are all reluctant to explore more sophisticated hypotheses. Few studies have performed experiments at neuronal network levels.

Like other higher order brain functions, the investigation into the neuronal mechanisms of placebo analgesia is proving to be difficult for clinicians and basic researchers. For example, there are individual differences in the response to placebos, called responders and non-responders. Certain populations of individuals show a significantly greater response to placebos than others. Evidence for environmental and social impacts on brain development is increasing; therefore, individual differences in higher order brain functions such as placebo analgesia is expected. Levine and colleagues (1978) performed a classic study on placebo analgesia [1]. Their hypothesis is based on the discovery of endogenous opioid peptides in the central nervous system. Placebo analgesia in patients was blocked by naloxone, an opioid receptor antagonist. These experiments indicate that the endogenous analgesia systems are likely to be activated during placebo analgesia, possibly at different levels of the central nervous system.

Major recent findings: alternations in ACC brain activity and placebo analgesia

Even though animal experiments are well designed and controlled, it is very difficult to test mechanisms of placebo analgesia in animal preparations. One major study using human brain imaging showed the activation of forebrain structures, in particular the ACC, during placebo analgesia. The correlation between ACC activity and placebo analgesia, as well as opioid analgesia, was shown in another study [2]. Considering the sensitivity of placebo analgesia to naloxone, it is proposed that increased ACC activity recruits endogenous analgesia systems by projecting innervations to the midbrain periaqueductal gray (PAG). Since a large number of opioid receptors are found in the ACC [3, 4], opioids are likely to be released within the ACC (as measured by increased activity during imaging) during placebo analgesia [2]. Activation of these opioid receptors somehow activates endogenous analgesia systems originating from the PAG, thereby producing analgesic effects [5]. Although functional imaging data is interesting and important, the explanation of these findings is obscure due to the limitations of human imaging techniques. Here, I would like to propose that several brain mechanisms might contribute to placebo analgesia, which may not be revealed by human imaging studies.

Activation of the ACC in the human brain

Neurons in the ACC receive inputs from highly wired networks (see [6]). Therefore, it is not surprising that activation of the ACC is reported during different physiological or pathological conditions. For example, ACC activity is increased by acute pain, opioid analgesia and placebo analgesia [2, 7, 8]. It is proposed that the ACC functions heterogeneously, playing various functions through its multiple connections with other cortical and subcortical nuclei. This heterogeneity indicates that ACC neurons are not solely responsible for physiological functions, such as pain, attention etc, and this complexity certainly makes it more difficult for scientists to obtain simple and easily interpreted results (Table 1).

Opposite types of neurotransmission in the brain: excitatory/inhibitory

It is well documented that neurons are highly connected by chemical synapses in the brain and spinal cord [9]. Excitatory synaptic transmission is mainly carried out by glutamate. In both the spinal dorsal horn and ACC, fast excitatory transmission is mediated by glutamate [3, 10, 11]. To prevent and control widely distributed excitatory transmission, neurons have local inhibitory synapses to prevent them from over-excitation and undergoing glutamate-induced neuronal death. Therefore, at any given moment, neurons that form excitatory and inhibitory synapses are likely to be continuously active. For this reason, it is critical to remember that measured neuronal activity may contain both excitatory and inhibitory neuronal activities, and that some of the measured activity may not play a physiological function.

Limitations of imaging and recording studies in monkeys and humans

Human imaging and awake monkey recordings provide physiological evidence for the role of neurons in performing a single, or a series, of functions. Under well controlled experimental conditions, ACC neurons show consistent patterns of activity [12, 13]. However, due to poor access to individual neurons in experimental subjects, many key questions remain unanswered. First, in most monkey studies neither the exact location nor the type of neuron (pyramidal versus local interneurons) recorded is known. In the case of human brain imaging studies, it is not very clear whether the increase in metabolic activity during testing is due to changes in neurons versus glia cells, inhibitory versus excitatory neurons (although, in most cases, investigators interpret this activity as excitatory neuronal activity), or local modulatory neurons containing neuropeptides. All of these factors limit our ability to compare discoveries from conscious monkeys or humans to the findings of molecular and cellular studies using rats and mice. Furthermore, we may still miss sub-threshold activity or activity in other key structures using human imaging studies. It is necessary to keep in mind that a big change may not necessarily be an important one or one directly related to the task.

Do ACC neurons serve as a higher cortical activator of the endogenous analgesia system (PAG-RVM-spinal cord)?

After discussing central neural transmission and the limitations of imaging studies, we are ready to explore one hypothesis proposed for placebo analgesia. That is, activation of the ACC triggers the endogenous analgesia system and modulates sensory transmission at the level of the spinal cord by descending inhibitory mechanisms, thereby contributing to placebo analgesia (see Discussion in [2]). Evidence for such descending inhibitory modulatory systems comes from electrophysiological, pharmacological, and behavioral studies in animals. For example, activation of the PAG or RVM by electrical stimulation or glutamate decreases responses of spinal cord dorsal horn neurons, including those that send ascending projections, to peripheral noxious stimulation (see [5, 14]) and inhibits the spinal nociceptive tail-flick reflex. Anatomical studies reveal that neurons in the dorsal horn receive descending inhibitory innervations. Application of a pharmacological antagonist can block theses inhibitory effects. This key hypothesis assumes that the connections from the ACC to the midbrain/brainstem trigger these descending inhibitory systems. However, recent studies show that activation of ACC neurons by electrical stimulation, or the activation of glutamate synapses, does not produce any analgesic effects [1519]. In contrast, facilitation of the spinal nociceptive tail-flick reflex, aversive learning or fear memory was reliably induced by ACC stimulation [20]. Consistent with this notion, inhibition of opioid receptors in the ACC inhibited excitatory synaptic transmission [3, 4], reduced nociceptive hot-plate responses, inhibited behavioral nociceptive responses to formalin injection and blocked chronic pain in some clinical studies [21, 22]. Furthermore, enhanced excitatory synaptic transmission and long-term plasticity were found in ACC neurons after tissue injury [23]. Intracellular recordings from ACC pyramidal neurons reveal that injury causes rapid excitatory responses in the ACC. Studies using genetically modified mice lend further support to the excitatory role of the ACC in chronic pain. Genetic over-expression of NMDA NR2B receptors selectively enhanced chronic pain [24], and genetic deletion of calcium-stimulated adenylyl cyclases (AC) 1 and 8 blocked persistent pain in various pain models [25]. In summary, enhanced excitatory transmission in the ACC is unlikely to activate endogenous analgesia systems.

ACC activity during placebo analgesia

An alternative explanation for the role of ACC activation in placebo analgesia is increased activity of local inhibitory neurons. Increased inhibitory activity within the ACC thus reduces the amount of excitatory responses to painful stimuli. By doing so, subjects report less pain (placebo analgesia). Based on the network connections that the ACC has with other pain-related neuronal structures, we propose that ACC activation can lead to placebo analgesia through the following neuronal mechanisms:

Mechanism I . Inhibition of pain-processing neurons in the ACC

Many neurons in the ACC respond to acute pain and the amount of this activation is related to pain unpleasantness. Activation of inhibitory neurons in the ACC can affect the excitability of these neurons by releasing GABA onto their postsynaptic receptors. Consequently, the excitability of ACC neurons is reduced, and neurons respond less to noxious stimuli (Figure 1a).

Figure 1
figure 1

A model neuronal network explaining placebo analgesia-related activation of ACC neurons. Placebo leads to activation of inhibitory neurons within the ACC. These inhibitory neurons then release an inhibitory neurotransmitter, GABA. GABA acts on postsynaptic GABA receptors to inhibit ACC neurons that are involved in pain perception. In some neurons, endogenous neuropeptides such as enkaphalin (Enk) may also be released to produce similar inhibitory effects (a). Inhibitory neurons may also affect ACC neurons that form descending facilitatory innervations with the spinal cord dorsal horn. Activation of inhibitory neurons within the ACC causes the reduction of descending facilitatory influences. The reduced facilitatory influence on spinal nociceptive transmission therefore produces analgesic effects.

Mechanism II . Activation of local opioid-containing neurons in the ACC

Similar to Mechanism I, neurons containing opioid peptides may be activated. Opioids may act presynaptically and/or postsynaptically to inhibit excitatory synaptic transmission and reduce neuronal responses to subsequent peripheral noxious stimuli. This mechanism could explain the fact that some placebo effects are sensitive to blockade by naloxone (Figure 1a).

Mechanism III . Inhibition of descending facilitatory modulation from the ACC

The release of the inhibitory neurotransmitter GABA and/or opioids will reduce the excitability of ACC neurons that send descending innervations directly or indirectly to RVM neurons. Consequently, descending facilitatory influences will be reduced (Figure 1b).

Mechanism IV . Mixed activation of excitatory and inhibitory transmission by placebo treatment with the net result within the ACC being reduced excitatory transmission.

Conclusion and future directions

Recent progress in neuroscience research provides us new opportunities to investigate higher order brain functions such as placebo analgesia. However, the mechanism is likely to be complex. Long-term plasticity of both excitatory and inhibitory transmission, postsynaptic trafficking and recycling of various receptors, activation of immediate early genes, and constant changes in synaptic structure and connections, are potential mechanisms for higher brain functions. Integrative approaches, from genetically manipulated mice to human brain imaging, will improve our understanding of placebo analgesia.

Table 1 Evidence for the pro-nociceptive effects of ACC


  1. Levine JD, Gordon NC, Fields HL: The mechanism of placebo analgesia. Lancet 1978, 2: 654–657. 10.1016/S0140-6736(78)92762-9

    Article  CAS  PubMed  Google Scholar 

  2. Petrovic P, Kalso E, Petersson KM, Ingvar M: Placebo and opioid analgesia-- imaging a shared neuronal network. Science 2002, 295: 1737–1740. 10.1126/science.1067176

    Article  CAS  PubMed  Google Scholar 

  3. Wei F, Li P, Zhuo M: Loss of synaptic depression in mammalian anterior cingulate cortex after amputation. J Neurosci 1999, 19: 9346–9354.

    CAS  PubMed  Google Scholar 

  4. Tanaka E, North RA: Opioid actions on rat anterior cingulate cortex neurons in vitro. J Neurosci 1994, 14: 1106–1113.

    CAS  PubMed  Google Scholar 

  5. Basbaum AI, Fields HL: Endogenous pain control systems: brainstem spinal pathways and endorphin circuitry. Annu Rev Neurosci 1984, 7: 309–338. 10.1146/

    Article  CAS  PubMed  Google Scholar 

  6. Zhuo M: Canadian Association of Neuroscience review: Cellular and synaptic insights into physiological and pathological pain. EJLB-CIHR Michael Smith Chair in Neurosciences and Mental Health lecture. Can J Neurol Sci 2005, 32: 27–36.

    Article  PubMed  Google Scholar 

  7. Rainville P: Brain mechanisms of pain affect and pain modulation. Curr Opin Neurobiol 2002, 12: 195–204. 10.1016/S0959-4388(02)00313-6

    Article  CAS  PubMed  Google Scholar 

  8. Wager TD, Rilling JK, Smith EE, Sokolik A, Casey KL, Davidson RJ, Kosslyn SM, Rose RM, Cohen JD: Placebo-induced changes in FMRI in the anticipation and experience of pain. Science 2004, 303: 1162–1167. 10.1126/science.1093065

    Article  CAS  PubMed  Google Scholar 

  9. Levinson JN, El-Husseini A: New players tip the scales in the balance between excitatory and inhibitory synapses. Mol Pain 2005, 1: 12. 10.1186/1744-8069-1-12

    Article  PubMed Central  PubMed  Google Scholar 

  10. Sah P, Nicoll RA: Mechanisms underlying potentiation of synaptic transmission in rat anterior cingulate cortex in vitro. J Physiol 1991, 433: 615–630.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  11. Li P, Calejesan AA, Zhuo M: ATP P2x receptors and sensory synaptic transmission between primary afferent fibers and spinal dorsal horn neurons in rats. J Neurophysiol 1998, 80: 3356–3360.

    CAS  PubMed  Google Scholar 

  12. Hutchison WD, Davis KD, Lozano AM, Tasker RR, Dostrovsky JO: Pain-related neurons in the human cingulate cortex. Nat Neurosci 1999, 2: 403–405. 10.1038/8065

    Article  CAS  PubMed  Google Scholar 

  13. Koyama T, Tanaka YZ, Mikami A: Nociceptive neurons in the macaque anterior cingulate activate during anticipation of pain. Neuroreport 1998, 9: 2663–2667.

    Article  CAS  PubMed  Google Scholar 

  14. Robinson DA, Calejesan AA, Wei F, Gebhart GF, Zhuo M: Endogenous facilitation: From molecular mechanisms to persistent pain. Curr Neurovas Res 2004, 1: 11–20. 10.2174/1567202043480189

    Article  CAS  Google Scholar 

  15. Calejesan AA, Kim SJ, Zhuo M: Descending facilitatory modulation of a behavioral nociceptive response by stimulation in the adult rat anterior cingulate cortex. Eur J Pain 2000, 4: 83–96. 10.1053/eujp.1999.0158

    Article  CAS  PubMed  Google Scholar 

  16. Tang J, Ko S, Ding HK, Qiu CS, Calejesan AA, Zhuo M: Pavlovian fear memory induced by activation in the anterior cingulate cortex. Mol Pain 2005, 1: 6. 10.1186/1744-8069-1-6

    Article  PubMed Central  PubMed  Google Scholar 

  17. Johansen JP, Fields HL, Manning BH: The affective component of pain in rodents: direct evidence for a contribution of the anterior cingulate cortex. Proc Natl Acad Sci U S A 2001, 98: 8077–8082. 10.1073/pnas.141218998

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  18. Ko SW, Chatila T, Zhuo M: Contribution of CaMKIV to injury and fear- induced ultrasonic vocalizations in adult mice. Mol Pain 2005, 1: 10. 10.1186/1744-8069-1-10

    Article  PubMed Central  PubMed  Google Scholar 

  19. Johansen JP, Fields HL: Glutamatergic activation of anterior cingulate cortex produces an aversive teaching signal. Nat Neurosci 2004, 7: 398–403. 10.1038/nn1207

    Article  CAS  PubMed  Google Scholar 

  20. Frankland PW, Teixeira CM: A pain in the ACC. Mol Pain 2005, 1: 14. 10.1186/1744-8069-1-14

    Article  PubMed Central  PubMed  Google Scholar 

  21. Lee DE, Kim SJ, Zhuo M: Comparison of behavioral responses to noxious cold and heat in mice. Brain Res 1999, 845: 117–121. 10.1016/S0006-8993(99)01956-3

    Article  CAS  PubMed  Google Scholar 

  22. Zhuo M: Glutamate receptors and persistent pain: targeting forebrain NR2B subunits. Drug Discov Today 2002, 7: 259–267. 10.1016/S1359-6446(01)02138-9

    Article  CAS  PubMed  Google Scholar 

  23. Wei F, Zhuo M: Potentiation of sensory responses in the anterior cingulate cortex following digit amputation in the anaesthetised rat. J Physiol 2001, 532: 823–833. 10.1111/j.1469-7793.2001.0823e.x

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  24. Wei F, Wang GD, Kerchner GA, Kim SJ, Xu HM, Chen ZF, Zhuo M: Genetic enhancement of inflammatory pain by forebrain NR2B overexpression. Nat Neurosci 2001, 4: 164–169. 10.1038/83993

    Article  CAS  PubMed  Google Scholar 

  25. Wei F, Qiu CS, Kim SJ, Muglia L, Maas JW, Pineda VV, Xu HM, Chen ZF, Storm DR, Muglia LJ, Zhuo M: Genetic elimination of behavioral sensitization in mice lacking calmodulin-stimulated adenylyl cyclases. Neuron 2002, 36: 713–726. 10.1016/S0896-6273(02)01019-X

    Article  CAS  PubMed  Google Scholar 

Download references


This work was supported in part by funding from the EJLB-CIHR Michael Smith Chair in Neurosciences and Mental Health in Canada, Canada Research Chair, NeuroScience Canada, CIHR and NIH NINDS 42722.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Min Zhuo.

Authors’ original submitted files for images

Below are the links to the authors’ original submitted files for images.

Authors’ original file for figure 1

Rights and permissions

Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution License ( ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article

Zhuo, M. Central inhibition and placebo analgesia. Mol Pain 1, 21 (2005).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: