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Walter Kennedy coined the term nocebo against the term placebo which denoted a drug which produced a beneficial, healthy, desirable and pleasant consequence. The nocebo signified just the opposite. The nocebo effect refers to the harmful effect that a drug can produce even if considered inert. The nocebo response is seen when a placebo is given and adverse effects are encountered. The response would have occurred due to some other factor. Kennedy used the term to denote the outcome caused by the negative expectation of a patient to the administration of a drug or ritual. Many people are now using this term to denote the pharmacologically predictive negative side-effects.
The negative expectations could be accompanied by emotional or affective states.
Expectations could be specific or generic.(Hahn, APA Books). Specific expectations are those symptoms which are definitely expected like vomiting or headache while generic expectations are indefinite or vague. It would not be a nocebo if exaggeration is a weakness of the patient. Being hypochondriac may give rise to a nocebo phenomenon whereas malingering does not. Only if the patient sincerely believes in a negative expectation and voices it, would the negative expectation be within the range of a possible nocebo (Hahn, American Psychological Association Books). People have different notions of seriousness of a symptom. What one calls serious, another may consider negligible. Some people have positive and negative expectations simultaneously which could be a healing outcome and a pathological outcome. That specific placebo side-effects are more likely in treatment of particular conditions was suggested by Pogge (1963);
17% of patients given placebo estrogen had nausea or vomiting, compared with 6% of patients given placebo analgesics and 2% of patients given placebo anti-obesity drugs. Nocebo hypothesis states that expectations of sickness increase the possibility that the expected sickness will occur (Hahn, APA Books).
Hahn also talks about how surgical patients could have convictions regarding their death. Patients who are convinced that they would die during surgery should not be operated upon.Weisman and Hacket (Predilection to Death ,1961). They surveyed the courses of 600 patients. They found that those who were convinced about their death usually did while those who were just unusually apprehensive did not. Another point is indicated by Hahn. A report of suicide in the newspapers could trigger a week of suicides in the countryside.
“During the week after Marilyn Monroe’s suicide in 1962, 197 suicides occurred in the United States–12% more than the number expected on the basis of past suicide patterns” (Hahn, APA Books). Another study found that teenagers are susceptible to suicides shown in the television. Girls were more bound to commit suicide in this manner. (Hahn, APA Books).
Brian Reid in his article in the Washington Post reported as follows: “Women who believed that they were prone to heart disease were nearly four times as likely to die as women with similar risk factors who didn’t hold such fatalistic views.” (The Nocebo effect: Placebo’s Evil Twin, 2002). According to him, the higher risk of heart disease had no relationship to the factors considered as causes like age, hypertension, cholesterol and weight but rather to the belief ‘think sick, be sick’.
“In cardiology, placebos influence disability, syncope, heart failure, atrial fibrillation, angina, and survival.” ( Olshansky, 2007). A doctor may unwittingly be contributing to placebo and nocebo responses. A good doctor-patient relationship can initiate placebo responses rather than the nocebo ones. It signifies the role of the doctor above the therapy. The human touch produces plenty of placebo responses merely due to a compassionate, smiling and efficient doctor. The future of Healthcare would be affected if this human touch is lost and we can be sure of the rise in nocebos (Olshansky, 2007).
Wise use of the placebos can benefit patients and strengthen the medical profession. Reports have been made about sham surgeries in cardiology which produced surprising results. Patients who had suspected coronary artery disease and who developed angina underwent sham procedures of mere skin incision or an internal mammary ligation. Both these groups of patients improved and even showed improved treadmill test results. Olshansky indicates that “ a cold, uncaring, disinterested and emotionless physician will encourage a nocebo response”. Patients would never accept depersonalised medicine no matter what progress is evident in the technological processes (Olshansky, 2007). Adverse unexplained drug effects and side-effects may be nothing more than a nocebo. The personal role that doctors have in patients’ lives has made the medical profession the most respected and honoured jobs.
600 patients in 3 cities of Italy, who had a history of drug reactions, were selected for a study by Liccardi et al (2004). They underwent a blind oral challenge and were administered indifferent substance and active drugs. Most of the reactions that were subjective in nature and very troublesome were itching, malaise and headache. Women complained more than men. The study confirmed that the nocebo effect occurs frequently in clinical practice. “In managing adverse drug reactions through oral challenge the nocebo effect is mandatory to recognize false positive responses” (Liccardi, 2004). Factors like patients’ expectations, previous experience, setting and appearance of the drug influence the nocebo effect. Capsules containing one tenth or half the usual strength or talcum were used in Verona and Naples. In Genoa, the active ingredient was again diluted by glucose which was also inert. Patients were observed for 6 hours. 418 females and 182 males were the participants. The inert substance provoked untoward reactions in 54 patients (27%) in Verona, 60 (30%) in Naples and 48 (24%) in Genoa (Liccardi et al, 2004).. The occurrence of nocebo effect was 27%. The conclusions stated that the placebo administration produces good effects in 35% of patients. Placebo administration does not differ in clinical efficiency from giving no drug (Liccardi et al, 2004). Nocebo effect is relevant to clinical trials. Two main factors which influence the nocebo effect are patients’ expectations and previous experience of drug reactions. The emotional state of a subject and the appearance of the drug also play a role. The nocebo effect was independent of social or environmental factors.
References
Brian Reid, “The Nocebo effect: Placebo’s Evil Twin”, 2002, Washington Post, Web.
Liccardi, G. et al, “Evaluation of the nocebo effect during oral challenge in patients with adverse drug reactions”, J Invest Allergol Clin Immunol 2004; Vol. 14(2): 104-107.
Olshansky, Brian; “Placebo and Nocebo in Cardiovascular Health Implications for Healthcare, Research, and the Doctor-Patient Relationship”, Journal of American College of Cardiology, 2007; 49:415-421.
Pogge RC. The toxic placebo. Part I Side and toxic effects reported during the administration of placebo medicine. Med Times 1963;91:773-8.
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