Brown_Ch15_(Hahn) - she-15 The Nocebo Phenomenon Concept...

Info icon This preview shows pages 1–6. Sign up to view the full content.

View Full Document Right Arrow Icon
Image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
Image of page 2
Image of page 3

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
Image of page 4
Image of page 5

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
Image of page 6
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: she-15 The Nocebo Phenomenon: Concept, Evidence, and Implications for Public Health Robert A. Hal-m This selection is about theflip side of the placebo fleet. The nocebo phenomenon rg‘ers to the process by which nega- tive expectations result in negative effects. in one hospital- based study reported here, 80 percent of patients who were given a glass of sugar water and told that it would make them vomit actually did vomit. is "power of suggestion" this powerfiil? Certainly this is a central theme in the prem- ous selection by [em-Strauss, but surprisingly this topic has not been systematically evaluated in bibmedicine. In general, _ placebo and nocebo phenomena seem to be viewed by bimnedieat scientists as a type of “noise” that contaminates the "real" interactions of cause and fleet. it would be worthwhile to change this conception—to see the placebo efi'ect instead as something to be understood and as power to be harnessed in order to improve medical care. This selection was written by an anthropologist for bio- medical scientists in the field ofpreventivc medicine. Robert Hahn suggests that the nocebo phenomenon should be con- sidered in health education programs. He suggests that the creation of medical categories of disease may be a double- edged sword: ”Categories of an ethnomedicine may not only describe conditions of sickness, but may also foster those con- ditions by establishing expectations that they may occur” (p. 12). A similar point is made in a recent book by Lynn Payer. The Disease Mangers (1994), in which she argues that the eaplosion of medical testing for risk factors like cholesterol may actually do patients more harm than good, although they generate enormous revenue for biomedical corporations. The value (3' looking at the nocebo phenomenon is not merely that we will remember the possible harm of engew dering negative expectations. It is also important to think about the power of belief in all types of medical treatments. In what ways do ethnornedical treatments function by pro- viding patients and their families with hope and by distract- ing everyone while the body heals itself? In this regard, if ethnomedical treatments are to be efective, they must follow the first rule of Hippocrates: “First do no harm.” The value of examining the nocebo phenomenon is that it provides an important insight into the placebo efl'ect, something that typically plays a role in the healing process. This selection was written for a public health~oriented audience, so it ofi‘ers many specific case studies as evidence. Readers interested in medical anthropological studies of the placebo infect may want to tool: at the work of Daniel Moerman (1991), fumes Dow (1986), or earlier work by Robert Hahn and Arthur Kleinman (1983). I As you read this selection, consider these questions: I What is the relationship between nocebos and placebos? Why do you think beliefs or expectations can be so poro- erful? Or do you? I is a person more suggestible to the nocebo efi'ect as a member or a group (for example, children in a cafete‘ ' rial? What role does social context play? I Many cultures have a custom of not talking specifically about a disease, for example, not using the term cancer to the patient. What do you think about this custom in relation to the nocebo effect as well as the principle of ‘ informed consent in doctor—patient communication? The nocebo hypothesis proposes that expectations of sickness and the affective states associated with such expectations cause sickness in the expectant. Resultant pathology may be subjective as well as ob- jective conditions. Some nocebo effects may be tran- sient; others may be chronic or fatal. An extreme form of the nocebo phenomenon was described in Cannon’s classic paper (1942) as "voodoo death.” Because ex- pectations are largely learned from the cultural envi- 138 ronment, nocebo effects are likely to vary from place . to place. The nocebo phenomenon, first named by Kennedy _ (1961) and then elaborated by Kissel and Barrucand ' (1964), has not been systematically assessed. In this re" View, I formulate a working definition of the nocdflo 3 phenomenon that relates nocebos and placebos; prer- sent a range of examples of nocebo phenomena: ; ' draw several implications for public health. . . «a. A WORKING DEFINITION OF 'TI-IE NOCEBO PHENOMENON ‘I The nocebo effect is the causation of sickness (or _ death) by expectations of sickness {or death) and by I associated emotional states. T‘wo forms of the nocebo effect should be recognized: in the specific form, the nibject expects 'a particular negative outcome and that -outcome consequently occurs; for example, a surgical patient expects to die on the operating table and does dies—not from the surgery itself, but from the expecta- tion and associated affect (Weisman and Hackett 1961; Cannon 1942). In the generic form, Subjects have vague negative expectations—for example, they are diffusely pessindstic-find their expectations are realized in terms of nonptoms, sickness, or death—none of which was specifically expected. Again, expectation plays a causal role.- The necebo phenomenon considered in this re- view is distinct from placebo side-effects (Figure 1). Placebo side-effects occur when expectations of heal- ing produce sickness, i.e., a positive expectation has a negative outcome. For example, a rash that occurs fol- lowing administration of a placebo remedy may be a placebo side-effect. Diverse placebo side-effects have been documented; one review reports an incidence of 19% in the subjects of pharmacologic studies (Rosen- zweig, Brohier, and Zipiel 1993). In the nocebo phe— nomenon, however, the subject expects sickness to be the outcome, i.e., the expectation is a negative one. Nocebos may also have side-effects, i.e., when nega- tive expectations produce positive outcomes or out— comes other than those expected. When Kennedy (1961) and Kissel and Barmcand (1964) first referred to the nocebo phenomenon, they did not distinguish placebo side-effects from the ef- fects of negative expectations. However, reference to voodoo death, for example, as an instance of the placebo phenomenon is etymologically inappropriate. Kennedy and Kissei and Barrucand distinguished placebos from nocebos only in terms of positive and negative outcomes, not also in terms of expectations. Kennedy's examples are all placebo side—effects, and Kissel and Barrucand did not separate examples of placebo side—effects from an example of nocebo in the sense proposed here: 80% of hospitalized patients given sugar water and told that it was an emetic sub— sequently vomited. What distinguishes nocebos is that the Subject has negative expectations and experiences a negative outcome. Schweiger and Parducci (1981) refer to nocebos as "negative placebos.” Nocebos are causal in the same way that com- monly recognized pathogens are, e.g., cigarette smoke of lung cancer, the tubercular bacillus of tuberculosis The Nocebo Phenomenon 139 H) (+) Outcome Expectation FIGURE 1 The Placebo Thesis: Relations Between Expectation and Outcome (From R. Hahn. Sidmess and Healing: An Anthropological Perspective, New Harm, CT: Yale University Press, 19951 (Surgeon General 1989; Harris and McClement 1983). That is, nocebos increase the likelihood that the sick- ness they refer to will occur, and this effect is not the result of confounding, i.e., the empirical association of the hypothesized nocebo with another cause of the condition. None of these exposures is a necessary or a sufficient cause of the given outcome. B. EVIDENCE OF NOCEBO PHENOMENA This review of evidence is divided according to the source or marmer of acquisition of expectations. It be- gins with (1) the effects of inner, mental worlds, moves to (2} the effects of nosological categories and self scrutiny, (3) sociogenic illness, or mass hysteria, and (4) the deliberate induction of sickness or symptoms. Inner, Mental World Mood, affect, and some psychiatric conditions are often associated with negative expectations (Amer— ican Psychiatric Association 1980). For example, hope- lessness is a prominent component of diverse forms of depression. Somatoform disorders such as hypochon- driasis and conversion disorder may also be asso- ciated with expectations of pathology. And some 140 Belief and Ettmomedical Systems anxiety disorders, too, may be associated with expec- tations of pathology. Panic disorder, for example, may involve a sense of "impending doom" and a fear of death (American Psychiatric Association 1980). Although several studies indicate an association of negative expectations and affect associated with psy- chiatric conditions and pathological outcomes (Black et al. 19853, 1985!); Newman and Bland 1991; Bruce et al. 1994; Weissman et al. 1990; Reich 1985; Friedman and Booth Kewley 1987; Wells, Stewart, Hays et a1. 1989), only the study by Anda and colleagues (1993) uses epidemiologic methods to control for the confounding effects of other risk factors. Anda and colleagues ex- amined the effects of depression on ischemic heart dis- ease (lHD) incidence and mortality in a sample of US. adults. They examined persons who were free from heart disease at the outset of the study and excluded Subjects whose initial depressed affect might have been the consequence of chronic disease. Depression was assessed from the General Well-Being Schedule {Dupu 1977). Anda and colleagues found that per- sons . th depressive affect were 1.6 times more likely to have nonfatal IHD and 1.5 times more likely to have fatal IHD than persons who did not have depressive affect, independent of other known risk factors for is- chemic heart disease. These researchers also examined the effects of hopelessness on heart disease incidence and mortality, and found a dose response—a critical cri- terion in the inference of causality. Greater hopelessness was associated with greater incidence and mortality. Considering that an 11.1% prevalence of depressed affect was assessed in the study cohort—a sample of US. adults-it can be estimated (as the "population at- tributable risk”) that approximately 26,000 deaths a year (i.e., more than 5% of US. IHD mortality and more than 1% of all [1.5. deaths) may be attribut- able to depression, independent of other risk factors. Mortality associated with depressive expectations is an example of the generic form of the nocebo phenom- enon. The other examples in this review are of specific nocebo phenomena. Nosological Categories and Self-Scrutiny In one specific form, cardiac neurosis or cardiophobia, patients are persistently fearful of heart attacks or other cardiac symptoms, and report chest pain, de— scribed by physicians as “non-specific.” Although these patients may not manifest recognized cardiac symptoms, there is evidence that belief that one is sus— ceptible to heart attacks is itself a risk factor for coro- nary death. Eaker examined women, 45 to 64 years of age, in the Framingham study for the 20-year inci- dence of myocardial infarction and coronary death (Eaker 1992). Women who believed they were more likely than others to suffer a heart attack were 3.7 times as likely to die of coronary conditions as were women who believed they were less likely to die of such symptoms, independent of commonly recog- nized risk factors for coronary death (e.g., smoking, systolic blood pressure, and the ratio of total to high density lipoprotein cholesterol}. Sociogenic Illness Sickness or symptoms may also occur when one per- son observes or learns of the sickness or symptoms in others. Knowledge of siclmess in others fosters an ex— pectation that one may also be subject to the same con- dition. Perhaps the best recognized form of contagion by observation are epidemics referred to as “socio- genic,” “psychogenic illness, mass hysteria,” or, in the workplace, “assembly line hysteria" (Colligan and Stockton 1978). Sirois (1974) reviewed 78 documented outbreaks of ”epidemic hysteria" reported between 1872 and 1972. Of these, 44% occurred in schools, 22% in towns, and 10% in factories. Twenty—eight percent involved fewer than 10 persons, 32% involved 10~30 persons, - and 19% more than 30 persons; 5% were of unreportetl- ' magnitude. (Whereas the largest outbreak noted by Sirois involved approximately 200 persons, an out— break has been described that involved 949 persons- IModan, Tirosh, Weissenberg et a1. 1983].) Only fe- males were involved in 74% of the outbreaks, only males in 4% (Sirois 1974). Outbreaks occurred more commonly among persons from lower socioeconomic classes and in periods of uncertainty and social stress. Convulsions were reported in 24% of outbreaks. ab- - normal movements in 18%, and fainting, globusfi congh/laryngismus, and loss of sensation in 11.5% each. Symptomatology changed over the 100 years surveyed, from more globus/cough/ laryngismus and abnormal movements to more fainting, nausea, ab? dominal malaise, and headaches. j Colligan and Murphy (1979) point out that sodas genie outbreaks are commonly associated with. source believed to be related to the symptoms. 9-8?! a strange odor or gas, new solvent, or an insect However. sometimes reported symptoms do not. biomedical knowledge of associations betwoen pom. tial toxins or pathogens and pathophysiology. PE affected often have repetitive jobs, are under un . stress, and/'or have poor relations with supe They may be in poorer general health and have - ' =-"='"' I: u I absent more often than persons who are not affected. ‘ golfigan and Murphy indicate that sociogenic out- breaks in workplace settings are substantially under» vjeporled. Sirois (1975) estimates that sociogenic outbreaks ' _. mm- in approximately one out of every 1,000 schools year in the province of Quebec. A review of recent ' school outbreaks in diverse countries indicates attack '1 rates (i.e., the proportion of persons exposed who ex- perience the condition) of 6%—48% (Arcidiacono, Brand, Coppenger, and Calder 1990). The study of Kerckhoff and Back (1968) of the 1962 "june Bug" outbreak in a Montana mill is one of the few to carefully reconstruct social patterns of the spread of a sociogenic condition. In the June Bug event, those affected fainted or complained of pain, nausea, or disorientation. Sixty-two (6.4%) of 965 workers were affected, 59 (95.2%) of them women; all those affected worked in dressmaldng departments. Persons affected were 70% more likely than controls to believe thaé the cause of the outbreak was an insect or other physical object. Persons affected were 62% more likely to have worked overtime at least two or three times a week than those not affected. Persons affected were less likely to go to a supervisor with a complaint or to be members of the union. They were 2.2 times as likely to be sole breadndnners, 5.6 times as likely to be divorced, and 30% more likely to have a child under 6 years of age. The outbreak began among women who were socially isolated, subsequently spread among women connected by links of close social relations, and finally diffused among women less closely con- nected. The phenomenon analyzed by Kerckhoff and Back might be described as ”mass somatization.” The effects of a person's social environment on sickness or illness behavior need not involve direct personal contact. An association has been found be- tween traumatic death or violence in the community environment and subsequent suicide or suicide-like behavior (Phillips 1974, 1977; Phillips and Carstenen 1986). In this instance, the first victim serves as a model with whom others may "identify.” For exam- ple, when newspaper or television stories about a suicide are released, the rate of suicide may increase in the following week; the greater the circulation of the newspaper, the greater the increase (Phillips 1974). After Marilyn Monroe's suicide in 1962, 197 suicides occurred in the United States during the following week—12% more than the number expected on the basis of past suicide patients (Phillips 1974). A recent study indicates that teenagers are more susceptible to televised publicity about suicide and that increases in Suicides are greater for girls than boys (Phillips and Carstensen 1986). The Nocebo Phenomenon 141 Motor-vehicle fatalities also follow newspaper stories of suicide. Phillips (1977) calculates that, on average, motor vehicle fatalities increase 9% above the expected rate in the week following front-page reporting of suicides in newspaper stories, and that, reporting in newspapers with greater than average circulation, the increaSe is 19%. Sickness/Symptoms Induced Social psychologists have conducted diverse exper- iments that demonstrate the effects of negative sug- gestion on the' experience of negative symptoms (Schachter and Singer 1962; Lancman et al. 1994; Jewett, Pain, and Greenberg 1990; Sternbach 1964; Schweiger and Parducci 1981). In one experiment, 47.5% of asthmatics who were exposed to (normally innocuous) nebulized saline solution and told they were inhaling irritants or allergens experienced sub- stantially increased airway resistance and changes in airway resistance and thoracic gas volume (Luparello, Lyons, Bleecker, and McFadden 1968). Controls who did not have asthma were unaffected by exposure to the same stimulus. Twelve asthmatic subjects devel- oped full—blown attacks that were relieved by the same saline solution presented therapeutically. (The researchers also refer to an asthmatic patient in an- other study whose allergy to roses was induced by plastic as well as natural roses, indicating that the ef- fect of the rose did not result entirely from its botanical properties.) In a follow-up, double-blind experiment, Lupar- ello, Leist, Lourie, and Sweet (1968) randomized asth- matic patients to four conditions: Two groups were given a bronchodilator, the other two a bronchocon- stricter; half of the group given each substance was told they were being given a bronchodilator, the other half that they were being given a bronchoconstrictor. For each substance administered, expectations in- duced by misinformation about the substance reduced its physiologic effectiveness by 43% (for the bron- choconstrictor) and 49% (for the bronchodilator). Another study was designed to evaluate a method for the diagnosis of psychOgenic seizures, reported to account for as many as 20% of ”refractory epilepsy" (Lancman et a1. 1994). Iancman and colleagues com- pared the effect of suggestion on the induction of seizure behavior in patients with psychogenic seizures and others with known epilepsy. Patients were told that a medicine administered through a skin patch would induce seizures within 30 seconds, and that re- moval of the patch would end the seizure. Of patients with psychogenic seizures, 77% manifested seizures N 1.42 Belief and Ethnomedical Systems when the patch was applied, with symptoms such as nonresponsiveness, generalized violent thrashing, and uncoordinated movements; 19% of these patients re— ported auras, and 44% showed postictal confusion and /or sleepmess. None of the patients with diag- nosed epilepsy manifested seizures. Finally, another study (Jewett, Fein, and Greenberg 1990), designed to evaluate a controversial method of food allergy testing, compared the effect of injecting the food substances—the test to be evaluated—with the effect of infecting saline diluent without the sub— stance in question on symptoms that included itching of the nose, watering or burning eyes, plugged ears, tight or scratchy throat, nausea, dizzinm, sleepiness, and depression. (Patients with a history of anaphylac- tic reactions or documented cardiac irregularity, or other severe reactions to their allergies were excluded.) in this double-blind study, the proportion of patients who experienced symptoms was not statistically dif- ferent in' patients given test (27%) and nowbo dilu- ent inj...
View Full Document

{[ snackBarMessage ]}

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern