Now, the drugs don’t work
Science Editor Mark Atwill discusses the nocebo effect through the work of the Wellcome Trust science writing prize winner Penny Sarchet.
In 1973, a man was diagnosed with cancer and given just months to live. After his death, an autopsy revealed the tumour in his liver had not grown. Clifton Meador, his intern, was quoted as saying “I do not know the pathological cause of his death,” and believed the man could not have died of cancer. Could it be, in fact, the worry – the expectation of death – that ultimately killed him?
If this were true, it would be an extreme example of the “nocebo effect”, which is the opposite of the placebo effect. For those unfamiliar with the term, the medical benefits of telling someone an inert sugar pill is wonder medicine is often startling. The adverse effects of information regarding negative effects are equally potent. It is this subject that won Penny Sarchet this year’s Wellcome Prize for science writing with her excellent essay.
The nocebo issue manifests itself most often in pharmaceutical trials when patients issued with a drug are pre-warned of its potential side effects. We then face an extremely difficult ethical quandary when considering the most beneficial treatment; should doctors warn patients about the side effects of the medicine they are getting?
Worryingly, the nocebo effect is insidious and notoriously contagious. Despite the frequency of reported cases, relatively little was known about how the effect occurs – until recently. A study by Oxford University scientists under Professor Irene Tracey showed that brain activity corresponding to nocebo pain is detectable in MRI scans. This proved on a neurological level that nocebo pain is registered in the brain as actual, tangible pain. A team under Fabrizio Benedetti at the University of Turn expanded upon the research and determined that the neurochemical cholecystokinin is responsible for the conversion of expected pain to the experience of actual pain. Blocking cholecystokinin in fact eradicates the pain associated with the nocebo effect; however, the anxiety remains.
Of course, the mistrust within society is so deep, that often doctors will over emphasise a side effect or a patient will have misgivings about the effectiveness of a treatment, which means the nocebo effect will doom the outcome before it’s even begun. Even more paradoxically, we must trust a doctor to gain the benefits of a prescribed treatment, however too strong a belief in their advice can result in a premature death.
The psychological ramifications of this research are startling. Allergies, back pain, food intolerances: while there are very real immunological and traumatic causes in some, others exhibit such conditions without simple medical explanations. Has anyone ever heard of the fake rose inducing symptoms of hayfever? This is perhaps a nocebo effect.
The sterile and medically saturated world we live in is, without doubt, healthier than that of antiquity. However, the burdens of hypochondria and anxiety that accompany it are very real. Perhaps it may be time to address the balance, to simplify and specify the warnings accompanying new products, to be clear and overt in explanations of the side effects of treatments without fear of a legal backfire. Perhaps, however, the psychology of the nocebo is far too complex to avoid. Indeed, if before reading this article, you were unaware of the existence of such an effect, are your chances of experiencing it now increased? It’s an interesting thought; I’d suggest reading Ms Sarchet’s essay.
