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The Nocebo Effect, Placebo's Evil Twin

Because of overscreening and the diagnosis of contrived or harmless ills, the so-called nocebo effect is wreaking havoc on otherwise healthy people.

It's all in your head
It's all in your head
Nic Ulmi

GENEVA — Like heroes in television series, the placebo effect has an evil twin: "nocebo." A placebo, of course, is "a substance having no pharmacological effect but given merely to satisfy a patient who supposes it to be a medicine." The idea is that the power of suggestion can sometimes heal in and of itself. Nocebo works the same way but with the opposite effect. Tell me I swallowed rotten food, for example, and my guts will writhe in pain.

But why? The brain's job is to manage the functions of the body, so it's not surprising that the information it absorbs affects the process. In The Nocebo Effect, American essayist Stewart Justman writes about the devastating effects of nocebo in diagnoses as varying as anorexia, chronic fatigue syndrome, depression, dissociative identity disorder, hyperactivity, and cancers of the breast and prostate.

Sometimes, symptoms are a direct result of the imagination, prompted by pharmaceutical propaganda or awareness campaigns. "Once they are put on the market, ideas on such and such illness are capable of triggering the illness itself," Jutsman writes. A diagnosis can deploy its noxious potential by "spreading suggestions in the mind of the patient."

The question of how commonly this happens apparently has been studied very little, partly because it's ethically dicey to conduct experiments that could potentially create medical problems for subjects. But there is some information to be gleaned about this "evil twin" from studies on the placebo effect. A particularly troubling one, published in the International Journal of Clinical Practice in 1998, involved a group of patients suffering from rheumatoid arthritis. Those who received a briefing about the illness felt worse than those who were simply treated without being told anything.

In other cases, studies indicate that large-scale screening often does more harm than good, leading to treatments that turn out to be more detrimental — or even more deadly — than the illnesses meant to be treated. The medical field itself warns of an "overdiagnosis" phenomenon. In fact, the subtitle of Justman's book is, Overdiagnosis and Its Costs.

Morphine and neurasthenia

The causal link of various ills sometimes seems obvious. "It appears that, as long as the residents of Hong Kong were not aware of the existence of anorexia in the West, this disorder did not appear among them, but once the notion reached the press and the public awareness in the 1990s, the phenomenon soared," Justman writes. It's as if "the affected people unconsciously formed their symptoms according to the model provided by the media."

It's similarly true with neurasthenia — basically, nervous exhaustion — a syndrome that was in vogue during the Belle Epoque. It "blossomed with the wealthy classes, until its disappearance in the early 20th century," Justman writes. Identified by American neurologist George Beard in 1869, the disorder was defined as a "heterogeneous symptom cluster," in which "the core features were held to be excessive physical and mental fatigue and muscle weakness." But the possible manifestations featured a list of 70 entries. "The brief and spectacular existence of neurasthenia proves how a designation has the power to organize and summon up symptoms," Justman writes.

In this way, some illnesses seem to reach people through social-cultural contagion. Placebo and nocebo demonstrate that the medical act, far from being a simple physical interaction, is really a full-fledged "social procedure." Justman notes that experiments even show that even a drug as powerful as morphine has a stronger effect when it is openly administrated, as part of a medical ritual, than when it is given to the patient without him knowing. A striking example of a syndrome being born via the therapeutic ceremony is so-called "multiple personality disorder," which most often appears from the moment the nursing staff asks the patient to name his alter egos.

Sleep and disarray

Are we talking about imaginary diseases, illnesses that were socially manufactured from nothing? In the case of depression, Justman suggests that conditions inherent to the normality of existence often wind up being medicalized — in other words, transformed into illnesses. It's the "common and temporary disarray, produced by life itself, which would resolve itself spontaneously if we did nothing," Justman writes. He calls them the "permanent features of the human condition," or at least "difficulties that are connected to the very nature of civilization."

The DSM-5, the latest edition of the American and international catalog on psychological illnesses and their symptoms, "unwillingly includes the argument according to which what we call depression can in fact be a justified response to life itself."

We could, of course, turn the question around: Should we accept ordinary disarray as an inevitable component of normality, or can we aspire to get rid of it? Like sociologists Allan V. Horwitz and Jerome C. Wakefield Stewart, authors of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder (2007), Justman defends the existence of melancholy in the human experience. Others nurture the utopian dream of eradicating all sadness.

"Ironically, one of the effects of overdiagnosing depression is that the fashionable antidepressants disrupt sleep," Justman writes. But "one of the most important healing factors in our lives lies in our ability to fall every night into a repairing sleep."

Consciousness is overrated

Is there a balance, a "good" medical limit we shouldn't exceed? The question is particularly pertinent in the cases of breast and prostate cancers. Mass screening for both men and women has led to the detection and treatment of "dormant" cancers that are potentially harmless. According to a 2013 study published in the British Medical Journal, for every death prevented via mammography, there are one to three additional deaths linked to treatments given to women screened for harmless cancers.

And according to a European study conducted between 2009 and 2012, screening reduces the mortality rate of prostate cancer, but for every man saved, 33 others become impotent or incontinent because of unnecessary intervention.

Several researchers suggest eliminating screenings. Justman goes further in recommending that we stop awareness campaigns, the major sources of nocebo effect. In his rush, he perhaps throws a few babies out with the bath water (especially in the field of psychological trauma).

But his paradoxical praise of unconsciousness will nevertheless be remembered: We live in the grip of a "cult of conscientization," but "consciousness is overrated." Our brains silently work on managing unconscious processes, and it's probably best not to disrupt it too much.

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