Warning labels can act as nocebos

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23 Responses to “Warning labels can act as nocebos”

  1. benenglish says:

    True story, if my mom was telling the truth.

    When she was young, gorgeous, and just starting in an office job (during WWII, she rebuilt aircraft generators…but that’s another story), one of the mid-level managers made a crude, physical, and distinctly unwelcome pass at her first thing one morning.  She was pissed.

    She got together with all the ladies in the office and had a quick meeting.  They’d all been groped by this guy at one time or another and were happy to help.  The plan: they all, individually and randomly that morning, would walk by his desk.  Then stop and look at him with a look of concern.  Then move on.  If he asked (and he did, to almost every one of them), they’d ask him if he was OK and mention that he didn’t look well.  According to mom, when they got a chance they really poured on the sympathy.

    He took it all to heart and left on sick leave before lunch.  They had so completely convinced him that he was sick that he stayed gone for an extra day.

    Costing the guy a day and a half of sick time was a small price for his forwardness but, given management attitudes back then, it was considered by all the ladies in the office to be a major win.

    Yes, “…the feedback we get from other people…has a physical effect on us.”  Definitely.  But I never thought it was “…a little insane.”  I thought this was just something that everyone sorta instinctively knew.

  2. Sam says:

    Maybe it makes sense to not read the list of side effects when taking a drug.  If you experience new symptoms, that’s useful information to have around when trying to determine if those are likely to be drug side-effects, but reading the list in advance might be counter-productive.

    • dragonfrog says:

      Unless you’re considering not taking the drug, or choosing a different one.

      For instance, I get nosebleeds very easily – if two drugs are both indicated for some condition I have, I’ll favour the one that isn’t likely to lead to nosebleeds (I even get nosebleeds from the recommended dose of dextromethorphan – nosebleeds from DXM are sufficiently rare not to make it onto the list in the package; I only confirmed it by googling and finding references to it on forums for people who drink ridiculous amounts of the stuff to get high).

      • Sam says:

        Yeah, that’s a good point, it makes a big difference if the drug is one where you have a lot of options (cold medicine) or one that you’re basically stuck with (chemotherapy).  And if there are specific things you’re looking out for, a chance to avoid those can outweigh the chance of psychosomatic side-effects.

        Maybe lists of side-effects should be divided in some way into those likely to cause nocebo symptoms (headache, nausea) and those unlikely to (including nosebleeds?).  Don’t know.

  3. pshaffer says:

    I’m a radiologist. We give contrast media (iodine containing drugs) for CT scans many times a day. Some years ago there was a discussion about whether informed consent should be obtained. Many people feel warm (big deal), some feel a little queasy (big deal). Some get hives, they go away in a few hours. But some, a very few, have an anaphylactic reaction which can be life threatening. There was research 20 years ago or so that demonstrated a sharp increase in  reactions, including moderate and severe reactions,  if the patients were told it might happen. Therefore, by giving information, you are putting the patient’s life at risk. My judgement is that it is unethical to risk the patient’s life in that way.
    It is also interesting that, while it is somewhat understandable that saying “you might feel nauseous” could promote nausea, the anaphylactic reaction is basically an immune reaction, which you wouldn’t really think would have much input from the brain. But it does happen. 

    • Antinous / Moderator says:

      I’ve signed a consent every time that I received contrast.

    • stumo says:

       That’s bizarre. I believe you – but the body is very weird.

      There are more things in heaven and earth, Horatio,

      Than are dreamt of in your philosophy.

    • GyroMagician says:

      I work in high-field MRI research. If you move too quickly in a strong magnetic field (as produced by the machine), it’ll make you feel dizzy and possibly nauseous. We used to warn volunteers about the nausea. But then we realised far more people reported feeling nauseous after we started warning them. Now we warn about the dizziness and make sure nobody moves too quickly. Reports of nausea have all but disappeared.

      For the record, nether effect is harmful, it just feels a bit unpleasant at the time.

    • $6143719 says:

      You forgot to add females also feel like they are urinating. Peeing and feeling a rushing warmth is the most common reaction I’ve always got. Ladies actually feel better that they are told to expect that sometimes.

      -The peson who does the consenting, starts the IV, fills out the forms, takes the history, talks to Radiologist/MDs to protocol the exam , and also inserts the enema for the rectal contrast. (Can you tell it was a tough day today? Lol)

  4. PhosPhorious says:

    I never read pill labels.  In fact, I draw pills at random from a large barrel like they use for Lotto, and swallow them eyes closed.  Maybe it’s aspirin, maybe it’s Adderol,  maybe it’s Viagra!

    The mystery is half the fun!

  5. kiptw says:

     Interesting. I tweeted back in April: “I just figured out how to double the effectiveness of a placebo: introduce side effects.” Glad I didn’t wait.

    • dragonfrog says:

      It’s done, and refered to as “active placebo” – using a drug with similar side-effects to the drug under study, but (hopefully) none of the effects you’re testing for (e.g. atropine as the placebo for tested drugs that cause dry mouth, or pins poked in non-acupuncture points as the placebo for acupuncture treatments)

  6. Getefix says:

    Are you all friggin’ crazy!?  There’s a damn good reason why you do not tell the general public that nocebos even exist, much less that they have measurable impact.  

  7. Antinous / Moderator says:

    We had chemo patients who would throw up in the parking garage before they even made it into the hospital for their first dose.  And they had the worst problem with chemo once they started the course.

    • ymendel says:

      Interesting. Atul Gawande talks about this sort of phenomenon in Complications, but as something that happens over time, not as nausea that precedes the treatment.

  8. What category does “this won’t hurt a bit!” fall under?

  9. Kimmo says:

    I’ve been saying for years there’s probably a nocebo basis to a class-action lawsuit against those responsible for plastering horrific imagery on tobacco…

    And before anyone attempts to counter with some crap about choice, they might care to look up the meaning of addiction. The fact is, many smokers don’t die of a horrible smoking-related illness, but presumably reminding them that they’re likely to will increase the proportion who do.

    Then there’s the simple principle that it’s just dumb to bring even more yuck into the world…

  10. ando bobando says:

    Karl Pilkington once asked “Does the brain control you or are you controlling the brain?” and of course Steve Merchant and Ricky Gervais laughed hysterically at him. But seriously… SERIOUSLY! Our brains are up to all sorts of @#$! we know nothing about!

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