Re: The Nocebo Effect

[Guest guest]

The below is relevant to previous discussions:

Is it a good idea to read about all the possible side effects of

medications you're taking?

http://online.wsj.com/article/SB122696995090235703.html

Not if you have difficulty concentrating, headaches, fatigue, dry

skin, irritability, a big project due, or an active imagination.

Research has shown that expecting to feel ill can bring illness on in

some instances, particularly when stress is involved. The technical

term is the " nocebo effect, " and it's placebo's evil twin. " It's not

a psychiatric disorder -- it's the way the mind works, " says Arthur

Barsky, director of Psychiatric Research at Brigham and Women's

Hospital in Boston.

SloanNocebos can even be fatal. In one classic example, women

in the multi-decade Framingham Heart study who thought they were at

risk for heart attacks were 3.7 times as likely to die of coronary

conditions as women who didn't have such fears -- regardless of

whether they smoked or had other risk factors.

Research deliberately causing nocebos has been limited (after all,

it's kind of cruel). But in one 1960s test, when hospital patients

were given sugar water and told it would make them vomit, 80% of them

did.

Studies have also shown that patients forewarned about possible side

effects are more likely to encounter them. In a study last year at

the University of Turin, Italy, men taking finesteride for enlarged

prostates who were informed that it could cause erectile dysfunction

and decreased libido were three times as likely to experience such

side effects as men who weren't told.

" People's expectations play a very important role in how they react

to all medications, " says Kradin, a physician and

psychoanalyst at Massachusetts General Hospital in Boston, and author

of " The Placebo Response and the Power of Unconscious Healing. " He

notes that about 25% of patients who get completely inert placebos in

clinical trials complain of side effects -- typically headaches,

drowsiness and dizziness.

For such vague complaints, one explanation may be that they are

always present in the general population. In a 1968 study of healthy

subjects not taking any medications, 39% reported fatigue, 14%

reported headaches and 5% reported dizziness. Only 19% said they had

no symptoms at all in the past three days.

Symptoms like rapid heart beat, dry mouth, nausea and diarrhea can be

traced to the body's response to stress (say, from fearing illness.)

Anxiety prompts the hypothalamus, pituitary and adrenal glands to

release a cascade of hormones that make the heart pound and the

stomach clench. Experiments have also shown that telling patients

they may feel pain triggers the release of the neuropeptide

cholecystokinin (CKK), which heightens pain sensations. When patients

are given a drug that blocks CKK, the nocebo pain vanishes.

" All that information is really for the doctor, not the consumer, "

says Barton Jr., a Birmingham, Ala., attorney who represents

drug makers. Under the Learned Intermediary rule, once a company

warns the prescribing doctor about a drug risk, responsibility in

case it occurs shifts to that doctor. " There's an incentive to warn

everybody about everything, but it fosters this climate of

supervigilance and alarm, " says Dr. Barsky.

If you are inclined toward health anxiety, reading up on your malady

or medication on the Internet can fuel your fears. " Once you are

anxious, there is all kinds of ambiguous information you can find

that will make it worse, " says Dr. Barsky.

Doctors may unwittingly foster placebo or nocebo effects by how

enthusiastically or warily they discuss medication. " Physician

communication with patients is the closest thing to magic. It gets

communicated in incredibly subtle ways—a flash in the eye, a smile, a

spring in the step, " says Moerman, an emeritus professor of

anthropology at the University of Michigan-Dearborn. Doctors may also

subconsciously transmit an expectation of pain. In a double-blind

study of 60 patients who had wisdom teeth extracted, when clinicians

thought they might be administering a medication that could heighten

the pain instead of lessen it, the patients reported much more pain—

even though they were really receiving placebos.

Should doctors discuss all those risks with patients, or can they be

a self-fulfilling prophecy? It depends on the patient and the

drug. " Patients should be made aware of anything that could be

dangerous, so they don't keel over on the street, " says Flavia

Golden, an internist in New York City. " But if it's minor like a

headache, I don't mention it. It's better to keep the channels of

communication open and say, 'Call me if you have any problems.' "

Some patients are more prone to worrying about side effects and

researching them, in which case a discussion of nocebos might be

helpful.

How should doctors treat a nocebo? With a placebo, naturally. " If

it's relatively minor, you can treat it with reassurance or say 'Take

two Tylenol and call me in the morning,' " says Dr. Kradin.

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Carruthers

Wakefield, UK