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Beware the Placebo Effect!

It’s All In Your Mind!

Everyone knows that a placebo — a fake medication or sham procedure, typcially used as a control in a medical trial — can nonetheless have a positive effect, relieving real symptons like pain, bloating or a depressed mood. The placebo effect is a result of the patient’s expectation that the treatment will help.

But expectations can also do harm. When a patient anticipates a pill’s possible side effect, he can suffer them even if  the pill is fake.  This “nocebo” effect has been largely overlooked by researchers, clinicians and patients. In an article recently published in the journal Deutsche Arzteblatt International, we and our colleague Ernil Hansen reviewed 31 studies, conducted by us and other researchers, that demonstrated the nocebo effect. We urge doctors and nurses to be more mindful of its dangers, particularly when informing patients about a treatment’s potential complications.

The placebo effect is a result of the patient’s expectation that the treatment will help.

Consider the number of people in medical trials who, though receiving placebos, stop participating because of side effects. We found that 11 percent of people in fibromyalgia drug trials who were taking fake medication dropped out of the studies because of the side efects like dizziness or nausea. Other researchers reported tht the discontinuation rates because of side effects in placebo groups in migraine or tension drug trials were as much as 5 percent. Discontinuation rates in trials for statins ranged from 4 percent to 26 percent.

In a curious study, a team of Italian gastroenterologists asked people with and without diagnosed lactose intolerance to take lactose for an experiment on its effects on bowel symptons. But in reality the participants received glucose, which does not harm the gut. Nonetheless 44 percent of people with known lactose intolerance and 26 percent of those without lactose intolerance complained of gastrointestinal symptons.

In one remarkable case, a participant in an anti-depressant drug trial was given placebo tablets — and then swallowed 26 of them in a suicide attempt. Even though the tablets were harmless, the participant’s blood pressure dropped perilously low.

The nocebo effect can be observed even when people take real, non-placebo drugs. When medical professionals inform patients of possible side effects, the risk of experiencing those side effects can increase. In one trial, the drug finasteride was administered to men to relieve the symptons of prostate enlargement. Half of the patients were told that the drug could cause erectile dysfunction while the other half  were not informed of this possible side effect. In the informed group, 44 percent of the participants reported that they experienced erectile dysfunction; in the uninformed group, that figure was only 15 percent.

In a similar experiment, a group of German psychologists took patients with chronic lower back pain and divided them into two groups for a leg flexion test. One group was told that the test could lead to a slight increase of pain, while the other group was told that the test had no effect on pain level. The first group reported stronger pain and performed fewer leg flexions than the second group did.

Just knowing that a drug can have side effects may increase your chances of suffering them.

A doctor’s choice of words matters. A team of American anesthesiologists studied women about to give birth who were giiven an injection of local anesthetic before being administered an epidural. For some women, the injection was prefaced by the statement, “We are going to give you a local anesthetic that will numb the area so that you will be comfortable during the procedure.” For others, the statement was, “You are going to feel a big bee sting; this is the worst part of the procedure.”  The perceived pain was significantly greater after the latter statement, which emphasized the downside of the injection.

“Words are the most powerful tools a doctor possesses, but words, like a two-edged sword, can maim as well as heal.” – Dr Bernard Lown

The nocebo effect presents doctors and nurses with an ethical dilemma: on one hand, they are required to tell patients about the possible complications of a treatment; on the other hand, they want to minimize the likelihood of side effects. But if merely telling patients about side effects increases their likelihood, what is to be done?

Better communication is the answer. When talking with patients, doctors and nurses often say things with intended negative suggestions, like “it’s just going to bleed a bit” or “you must avoid lifting heavy objects — you don’t want to end up paralyzed.” We recommend more extensive training in communication for doctors and nurses, to help them use the power of their words appropriately. As the great cardiologist Bernard Lown once said, “Words are the most powerful tools a doctor possesses, but words, like a two-edged sword, can maim as well as heal.”

This article writtenby Pail Enck, a professor of psychology at the University of Tuebingen and Winfried Huser, an associate professor of psychosomatic medicine at the University of Munich first appeared in the August 12, 2012 issue of The New York Times.

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