‘The big education for me is that civilisation is fragile and can be destroyed in a heartbeat' - Jeremy Brade, former peacekeeper in Sarajevo.

Monday, June 14, 2021

Health: the Nocebo Effect

After my wife had a broken wrist repaired she went to see the physiotherapist, cradling her wounded wing in its arm sling. ‘Don’t do that,’ said the physio, ‘because you’re sending a message to your brain that your arm doesn’t work.’

Not all medics have that psychological insight. My GP friend told me long ago that doctors were untrained in communication and tended to deal with patients like motor mechanics fixing cars.

Yet the mind is a powerful force in health, for good or ill. We have all heard of the placebo effect, whereby a pill with no active ingredient that could help the patient physically still seems to have beneficial effects for some who believe in it; few of us will know about its negative counterpart, the ‘nocebo effect.’ https://www.webmd.com/balance/features/is-the-nocebo-effect-hurting-your-health

‘Patients, their symptoms and their healing are negatively affected by the omission of placebo effects, by nocebo effects and by negative suggestions,’ says this writer https://www.frontiersin.org/articles/10.3389/fphar.2019.00077/full , giving a counter-example of how a doctor examining an injured leg could end on a positive note by then asking about the other one that’s fine, assisting the patient to see him/her/zirself as OK overall.

Positivity is infectious. My friend said that when he was a houseman encountering one consultant in a London hospital he would greet him with the conventional ‘How are you?’ only to be blasted with an enthusiastic ‘AB-solutely fan-TAS-tic!’; the buzz he got from that would last him all day.

Negativity, on the other hand, can affect you even when you are unconscious and on the operating table. There is evidence that anaesthetised patients ‘particularly recall conversations or remarks that are of a negative nature concerning themselves or their medical conditions. The most frequently reported postoperative effects were sleep disturbances, dreams and nightmares, flashbacks, and daytime anxiety.’ https://pubs.asahq.org/anesthesiology/article/87/2/387/36215/Learning-and-Memory-during-General-Anesthesia-An Conversely, an experiment using headphones and positive messaging on anaesthetised surgery patients has yielded good results https://www.bmj.com/content/371/bmj.m4284 .

Negativity can also bias clinical decisions. My wife needed an operation for a condition that was a daily and growing misery, but the NHS consultant who spoke to her (on the telephone, of course) made dubious noises, referring more than once to her age (was the subtext, ‘you may not survive the operation’, or was it ‘not worth it, for an oldie like you’?) Having some savings, we went private and that consultant – who could see her, not just her medical records – told her ‘You’ll sail through that, no difficulty’; as she did, and her quality of life has greatly improved as a result.

If you want to know why men don’t visit the GP as often as women, here’s an example. I was getting blurred vision in the evenings – ‘tired eyes’, I don’t wear glasses and never did – but listened to a relative’s advice and saw the GP. Blood test results (‘might as well look for other things while we’re on’) showed I was officially Type 2 diabetic. Gotcha!

Next thing, I’m in with the nurse, who tells me to take off shoes and socks and starts poking my feet with a feather quill, asking me if I can feel that? Jab yes jab yes jab yes, on and on. Now you may think that if I’d lost feeling in my feet or hands I’d have noticed, but nothing was going to stop the Procedure. I was also sent to the optician, who really did give me blurred eyes; all fine. Since then, years ago, I have been repeatedly chivvied for follow-up blood tests and vision screening; I resist.

For underneath all that well-intentioned busy-ness is a subliminal message: ‘You’re on the slippery slope, chum. It’ll start with tingling (I would make a good subject for hypnosis, I obediently started to tingle for days after the poking session – then no more, as I recovered my balance); then numbness, amputation, the lot – the helter-skelter ride down to the wooden box. We’ll do all we can to help, but, you know, inevitably…’

It also helps confirm the inalienable importance and role of the Healer. I am now not an autonomous human being, but a Patient, who must have many Examinations and Interventions and may never be released.

In a way it’s a bit like psychotherapy; yet while Freudian analysts have to undergo training so that they don’t get their egos damagingly mixed up with their patients, I’m not sure how fully this power-relationship is addressed in the rest of medicine. I know that the need to gather relevant information can lead on to nosey-parkerism: once, while waiting to see my GP, an assistant fixed me with a smile and asked whether, since I’d been to Oxford, I’d been a cannabis user. Just what I needed: to confess to a crime and have it put on my far-from-confidential medical records! What private data about you, dear reader, will be ‘scraped’ off after 23 June, and how may it be used? https://hitchensblog.mailonsunday.co.uk/2021/05/if-you-dont-want-your-private-medical-records-scraped-and-given-to-third-parties-heres-what-to-do-yo.html

Some may feel I’m over-reacting, but perhaps it’s down to a stereotypical gender difference in attitudes to health treatment. Men tend to have two states: (1) alive; (2) dead; anything else and we tend to prefer (2). When I was an IFA and Long Term Healthcare insurance came in, we were told that on average, women survive in nursing homes for around three years; men, eighteen months. Women are far more commonly on antidepressants than men, yet the latter are three times more likely to take their own lives. This will be put down to stupid machoism – in our times, any sign of stubborn, manly do-or-die go-it-aloneness is denigrated – without considering what society (throughout history and before) really, after all the PC nonsense, expects of men: to be defenders, providers, winners.

Morale is crucial. Australian aboriginals could be killed by having a curse-bone pointed at them, dying despite the best efforts of modern medicine to save them https://en.wikipedia.org/wiki/Kurdaitcha#Bone_pointing . Until we take into account the mind and the effects on it of implicit attitudes and messages, healthcare may be impaired in its efficiency and its ability to address inequalities. More widely, we need to look at how we talk to ourselves and others; cheeriness may sometimes be irritating, but negativity can sour joy in life and even destroy it.


A K Haart said...

Spot on - I'm sure you are not over-reacting. Morale is important, it's one of the things I so dislike about coronavirus policies - the official inability to be upbeat. It would help but of course that would in turn lead to more questions.

By the way, can I buy a curse-bone and point it at the TV?

Asking for a friend.

Paddington said...

Had I not had the quadruple bypass, all of the evidence indicates that I would have had a heart attack two years ago. And, given the arteries involved, it would have been fatal. Only 5% with my particular blockage even make it to the hospital.

As for placebo and nocebo, it turns out that the effects are a) temporary and b) only psychological, meaning that no healing or injury results from them. At most, they can give rise to short-term pain, or lack thereof.

Paddington said...

And, of course, it turns out that the 'pointing of the bone' results are a myth, in terms of suggestion or magic.

On the bright side, you learn something every day:

"In some cases pointing the bone is the final act in a tribal sentence, and if the sentence is execution then the tribes sanctioned assassins, the Kurdaitcha, do their duty, taking years if necessary to track down the accused.


Sackerson said...

@P: I asked yesterday about the random scan you had - can't have it until I manifest 'symptoms'.

The link about bone-pointing gives a hospital case from 1953 - the man had not been injured or poisoned.

Sackerson said...

Btw the hunting party, according to that 1953 account, is to find the victim and point the bone. Aboriginals had no compunction about physically destroying others, inc. women and children, either as being from a rival tribe or for infringing taboo paths or places reserved for men; bone not needed.

Also, re the belief some have that the psyche and soma are unconnected, here is something local to you:


Paddington said...

@Sackerson - If you are talking about the Calcium screening that led to my bypass, that was 'free' and widely available locally here. There is a US fetish about saving certain lives at all cost.

Sackerson said...

@P: Not here - 'must help the NHS save pennies.' The 'health screen' that they do do, is not much effective -


- whereas an echocardiogram or similar could be a real life-saver as in your case. And I understand that in your case you didn't have 'symptoms'? In which case, even more important to have the scan?

Paddington said...

@Sackerson - In my case (and I strongly suspect our father's) that is the way of it. The one fully blocked artery is not called the 'Widowmaker' for nothing.