The Nocebo Effect

There is an everyday  occurrence in modern clinical  psychiatry that is seldom discussed, poorly understood and constantly overlooked in daily practice.

It has a myriad of clinical, social and psychological consequences. It facilitates the bashing  of the pharmaceutical industry and modern psychiatry, it promotes the so prevalent negative stigma towards mental illness. The treatment for it is usually meaningful psychotherapy, but most therapists don’t know much about it, and many have never even heard of the concept. The phenomenon is present in just about every specialty in medicine, with the exception of maybe pathology or diagnostic radiology. Ironically it drives up the cost of health care, increases the practice of defensive, if not paranoid medicine, and sends us into a quandary when trying to help our patients. It leads us on quests and safaris to find a treatment, any treatment that will be beneficial, and somewhere along the lines we end up working a lot harder than the patient, to try to help and improve the patient’s well-being. Working and trying harder than the patient, is a political powder-keg and a taboo and unacceptable thing for doctors to admit on the internet or anywhere else. Yet at least in psychiatry it can be quite diagnostic of the phenomenon.

Of course I am talking about the widely non-discussed, little known: Nocebo effect. The nocebo effect has more relevance and significance than the more widely known placebo effect, because at this point in time, it permeates state of the art clinical care. The placebo effect has yet to find its footing in clinical relevance or from an ethical and legal standpoint. Contrary to popular belief in this country we don’t get to prescribe placebos; yes we all know of instances where a homeopathic dose of something seems to have profound unexpected benefit. Yet it clinically satisfies standards of care, for all the scrutinizers of physicians and health care delivery; so not quite placebo.

Nocebo  from Mosby’s dictionary: an adverse, nonspecific side effect occurring in conjunction with a medication but not directly resulting from the pharmacologic action of the medication. Now why would this be important in clinical practice?

Have you ever seen a patient where they have had one ALMOST catastrophic event after another, after introducing med after med, after med, a rash, chest pain, N and V,  multiple ER visits to reveal no physiological problem or cause: except an adverse event associated with a new medication. Ever wonder why? No not every patient could possibly be a slow metabolizer; it happens with renally or hepatically excreted meds. It’s not about the med. I will repeat it is not about the MED.

No one will deny that there is a such thing as side effects, adverse events and real allergic responses.
but: Here is how the nocebo effect really works.

Consider that the physician, is an ancient archetype, the healer, the shaman. Long before Asclepius, the archetype has been around since humans walked upright and maybe before. It became synonymous through the centuries, with caring, beneficence, nurturance, attributes one would consider remarkably similar to basic parenting. In modern society at least over the last 120 years or so, that white coat symbolizes the healer. It is a powerful symbol.

A medicine becomes the transaction, a metaphor, a symbol of the connection between the healer and the patient.  To understand this one must think beyond the simple physiological and pharmacological effect of the med. Just think human nature. Giving that med, that tincture that potion is timeless. It is the ultimate sign of human trust. and an atavistic connection of the modern physician-patient alliance.  Yes we all know our patients go to Walgreens to get the med, but stay with the archetype.

The symbol of the medicine runs deep even in modern day. If you fortunate enough or maybe unfortunate enough, to have tens of thousands of patient contacts a year, and you prescribe meds that are taken on a daily basis, chances are that your patient who takes that med daily and sees your name on the bottle every dose is consciously and or unconsciously considering that relationship with you, that one based on trust.

Now in psych and in medicine in general we have a lot of patients severely traumatized psychologically, in severe pain mentally and often physically. They are often so hurt, so wounded, that no doctor or med is good enough or seems to work. They keep stepping up to the plate, doctors keep trying. Many of these patients are often so abused, by commission (e.g. violence) and omission (lack of nurturance and positive regard) that they may be narcissistic, entitled and demanding. They trust the doctor consciously and completely and blindly. But yet they are wounded and looking for what never was- that nurturance and positive regard needed way back when.

But the unconscious which remembers a lot longer than the conscious mind is expecting to be let down, to be hurt, remember the symbol of the white coat, and what it means, and then remember that patient may have been hurt and traumatized and psychologically abandoned by every figure in their lives, that based on human nature, was supposed to have been there for them. The doctor patient relationship becomes a symbol of all those broken alliances when their personality was developing, when they were first let down.  The unconscious mind can do some pretty amazing things to the rest of the body.

Psychosomatic may be a term (everyone has heard of) that does not do justice to that mind body link.
If you work in psychiatry and start a patient on a new med, ever did you notice two weeks later when you ask about the med, the patient will often tell you all the things the med did to hurt them, side effects etc? Sometimes you have to cognitively retrain and suggest that you and the medicine are not there to hurt of make the patient worse. A little work in this area, on the symbolism of meds and working on that therapeutic alliance can go a long way, in decreasing nocebo effect, enhancing the physiological effects, and understanding the expectations and limitations of modern pharmacology.

About: Joseph J. Sivak MD is the author of the Alzheimer's Memoir "When Can I Go Home?". He blogs at http://alzheimmers.blogspot.com/

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