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'I Will Not Be Pleased' -- Your Health and the Nocebo Effect

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For decades the placebo effect has existed basically as a nuisance, so far as the medical profession is concerned. Some people benefit from being given a sugar pill instead of an actual drug. This remarkable result cannot be marketed, however. It doesn't fall within the ethics of medicine to prescribe fake drugs. Therefore, a doctor in practice, whose training has drummed into him that "real" medicine means drugs and surgery, will shrug off the placebo effect as psychosomatic, or "It's all in your head."

This attitude shuts down a fascinating possibility, that a patient's expectations plays a major role in being well or getting sick.

The placebo effect is real medicine, because it triggers the body's healing system. One could argue that this is the best medicine, in fact, since a.) drugs do not trigger the healing system and b.) the placebo effect has no side effects. Staying well means that the body is taking care of itself -- and you -- through a feedback loop of chemical messages. Circulating throughout the bloodstream, lymphatic system, and central nervous system, chemical messages are crucial to the healing system, because they keep every cell in communication with every other.

Like it or not, every thought, decision, and action influences this feedback loop. The "or not" is important. Unwittingly, we damage the body's natural state of health with negative input. The fact that this input comes from the brain means that thoughts, moods, and expectations, however intangible, get translated into chemical messages just as surely as molecules of aspirin or glucose. You and I bear the responsibility of sending positive messages to our cells as opposed to negative ones.

This is a prelude to an overview of the nocebo effect that recently appeared in the New York Times. The placebo effect, which is based on a person's positive expectation, has been widely studied. Its opposite, the nocebo effect, has not. But clearly, a negative expectation can be powerful. Subjects who volunteer for drug trials sometimes drop out, for example, because the side effects of the new drug are too severe. This is true even when the side effects are being induced by a sugar pill and not a real drug. To quote from the Times article:

We found that 11 percent of people in fibromyalgia drug trials who were taking fake medication dropped out of the studies because of side effects like dizziness or nausea ... The discontinuation rates because of side effects in placebo groups in migraine or tension drug trials were as much as 5 percent.

If these percentages seem rather low, consider the following remarkable finding: A study on lactose intolerance took a group of subjects who complained of intestinal problems caused by lactose, the sugar found in milk. Some of these people had been diagnosed with lactose intolerance; others only suspected that they had it. When asked to take lactose by the experimenters, "44 percent of people with known lactose intolerance and 26 percent of those without lactose intolerance complained of gastrointestinal symptoms" -- and yet all had actually been given glucose, which doesn't do harm to the intestines.

The two authors of the Times article, Paul Enck and Winfried Häuser, are German professors of psychology and psychosomatic medicine respectively, and their overview covered 31 studies in the nocebo effect. The most telling case they refer to was a patient who took 26 placebo antidepressants in a suicide attempt and had his blood pressure fall "perilously" low, as would happen overdosing on real antidepressants. What makes this case so telling is that it demonstrates that the body can turn any mental intention into its chemical correlation.

The key to the placebo effect is that the patient expects a good outcome, while in the nocebo effect the expectation is of a bad outcome: I will be pleased versus I will not be pleased. Set aside the medical implications. We make judgments about all of our experiences every day, expecting them to turn out well or badly. Does this point to a holistic placebo versus nocebo effect? We'll explore that possibility in the next post.

(To be continued)

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