The Role Doctors Play
In Part One, I discussed a nocebo analysis that “went on to suggest some strategies that could be used by medical professionals to mitigate the potential damage that the nocebo effect could cause in susceptible patients”.
Researchers into the subject of nocebo are suggesting that it is time for doctors to reevaluate their conventional medical beliefs about pain management. For example, doctors currently believe that they are minimizing anxiety by preparing the patient for the worst. So, they might say something to the effect of, “this is going to hurt quite a bit”.
Yet, one study showed that the words used by a doctor before injections affected the amount of pain the patient experienced. “The more frequently the words “sting,” “burn,” “hurt,” “bad” and “pain” were said, the more discomfort felt by patients.” (Source)
In a group of patients receiving treatment for back pain, a stretch test was administered. If the doctors giving the test suggested that it might hurt, patients were more likely to report pain, however if they said nothing about potential pain, the majority of patients reported no pain.
Unfortunately, some doctors consider changing the focus on the negatives to positives, to be at odds with properly informing the patient about procedures, and potential dangers or discomforts that may ensue (“informed consent”).They consider this an “ethical dilemma”, yet is it really better to tell the patient they have six months to live, or never will walk again?
(And I have met many people who have been told such discouraging things, only to get angry and defy such predictions. Evidently, the angry rejection of such a diagnosis is important to the healing process. Perhaps this is necessary to escape the belief system being foisted on them.)
But, the fact of the matter is belief, at the very least, influences the immune system, and giving patients a positive framework to work from, along with hope, are in and of themselves, of healing benefit.
The authors of this study on words used by doctors, suggested that doctors “emphasize positives (re-framing warnings into phrases such as “the majority of patients tolerate this well”) and, in some cases, actually getting permission from patients to keep them in the dark about certain mild side effects”. (Source)
The nocebo effect clearly has the potential to be seriously dangerous, as with the young man referred to in Part One, who almost died from it. And he is not the only example. Patients who enter into surgery expecting they might die, are more likely to have serious complications and delayed recovery. In one particular case, a man with a tumor was told that it had metastasized and that he only had so many months to live, and he indeed died within that time line. However, his autopsy revealed that the tumor on his liver had not in fact metastasized, so he was in no danger, thus there was no real reason that he died. (Source)
There are few experiments on the nocebo effect, as doctors would consider it unethical to try and create an illness in a patient. However, there is a study that has determined the nocebo effect follows a specific pathway in the brain, and it is possible to biochemically block that pathway.
Cholecystokinin (cck) is a hormone found in both the gut and the brain. In the gut, cck, and its variants, regulate the release of bile along with other digestive enzymes. In the brain, however, two variants of cholecystokinin (cck-a and cck-b), when activated, bind to receptors that reduce the amount of dopamine in the brain. This, in turn, increases levels of depression and anxiety in individuals, which makes us aware of pain, and helps us to focus on it (which is an evolutionary survival mechanism).
Happiness and relaxation, on the other hand, reduce pain levels. So, when patients were injected with something that blocked the cck receptors (benzodiazepine, diazepam) allowing the dopamine to rise, the nocebo effect lessened, and patients had better outcomes, with less sensations of pain. (Study)
This leads me to think that taking dopamine precursors prior to medical events might help reduce the pain response. (Dopamine precursors include acetyl-L-carnitine, L-tyrosine, NAC, avena sativa, and mucuna pruriens.)
Bone Pointing
Before concluding this analysis of the nocebo effect, I’m going to take a quick look at it from an anthropological perspective, one I believe that informs us of the deep roots this process has in our distant history, and perhaps even in our DNA.
“Bone pointing” is an ancient method of execution used by the Aborigines of Australia, and is highly effective to this day. So much so that Australian medical staff are often trained to deal with illnesses caused by bone pointing. The bone used in this curse may be made from emu, kangaroo, or human bones (or sometimes even just wood).
This form of ritual which causes death is not unique to the Aborigines, but has been found to occur around the world.
“Victims become listless and apathetic, usually refusing food or water with death often occurring within days of being “cursed”. When victims survive, it is assumed that the ritual was faulty in its execution. The phenomenon is recognized as psychosomatic in that death is caused by an emotional response—often fear—to some suggested outside force and is known as “voodoo death”. As this term refers to a specific religion, the medical establishment has suggested that “self-willed death”, or “bone-pointing syndrome” is more appropriate.” (Source)
Conclusion
Perhaps we are not as modern as we like to believe. According to Ronald Wright, in “A Short History of Progress”,“…we are running twenty-first-century software on hardware last upgraded 50,000 years ago or more. This may explain quite a lot of what we see in the news”.
And, when we consider the outcome of placebo knee surgery, we have to consider that perhaps medicine is not the scientific marvel that we have been led to believe it is. (See my newsletter on Dr. Robert Mendleson, and how medicine is the new religion. I also highly recommend this article, “Altars and Icons – The Surgical Suite as a Sacred Ritual”, which opens with:“The surgeon as priest, shaman, or healer performs sacred rituals every time he or she steps into the operating room.”)
As I was wrapping this up I found a short article on the placebo effect by the renowned complementary medicine advocate, Dr. Andrew Weil.
He offers a nice summary of the observed effectiveness of placebo on a variety of health issues. “It can relieve severe postoperative pain, induce sleep or mental alertness, bring about dramatic remissions in both symptoms and objective signs of chronic disease, and initiate the rejection of warts and other abnormal growths.”
Reading this reminded me of when I saw Dr. Weil lecture in San Francisco (in the mid-80s). He told the story of interning at a hospital and hearing a couple of young doctors telling an anecdote about a patient. This older gentleman had a consistent problem with warts all over his body. Nothing attempted by the doctors had ever helped the situation, and one day he came in, as he did fairly regularly to the eventual annoyance of the doctors. So, that day the two young doctors decided to have some “fun” with the patient and told him they had a new experimental regimen that had shown some success in wart removal.
They then subjected him to some type of light exposure that looked fancy but had no relevance to his condition (my memory is rusty but perhaps some kind of new ultraviolet or infrared light therapy). One treatment would be all that was required and it would either work or not. You can see where this is going. The man came back a few days later and all the warts had disappeared from his body. The doctors told this story frequently and with great amusement.
Dr. Weil found it appalling that this was all the event meant to them: a good story. It never crossed their minds that this was an unfathomable result, and that perhaps they should look more into the potential of the placebo effect.
Another unfathomable concept that Dr. Weil mentions in his article is this: “In addition, recent research has shown that the placebo response can occur even when patients are completely aware that they’re getting the equivalent of the sugar pill.”
I used to have a running joke during my many years giving nutritional advice in vitamin stores. I would suggest that one should bring to market a product called “Placebo” which could scientifically claim to cure 30 - 35% of ailments. But of course this wouldn’t work because, as I thought then, the effect only works if one is unaware whether they are getting the real drug or the sugar pill.
Quite frankly, I can’t even understand how it could work if one knows it is a placebo. Unless we refer back to the material I referenced at the beginning of this conclusion. The power of the white coat, the semi-religious belief in the medical system and the shamanic primeval circuits that medicine actually runs on. But that is a subject well beyond the scope of this newsletter. (As the shaman Don Juan said, “power lies in the function of belief, it doesn’t matter what belief it is attached to”.)
However, before I close, let’s briefly consider how children have a more flexible and open belief system than adults do. Would this then not make them more “susceptible” to the placebo effect?
Well, Weil also mentions a study “about placebo responses in the treatment of migraine headaches in children, in which the authors note that compared to around a 35 percent response rate in adult migraine trials, the positive response can be upward of 50 percent in children”.
Within this study, the researchers, unlike our young wart-healing doctors, “suggest that instead of focusing on eliminating placebo responses in clinical migraine trials, the focus should be redirected towards understanding the underlying mechanism responsible.” In other words, if they could get a grasp on how to elicit the placebo effect more effectively, they could possibly get an even higher response rate from children suffering from migraines, and reduce the necessity for drugs. (Source) While this approach is unlikely to get much research funding due to its outcome likely leading to less drugs being sold, it is an approach that honors the true spirit of science and medicine.
So, it is quite likely we have more healing potential within us than outside of us, and we need to learn to participate in our own healing, rather than abdicating responsibility for our health to so-called experts, and totally depending on others to take care of us, as we are encouraged to do by the medical profession.
Contrary to the best efforts of science and medicine, magic is still alive and it appears to reside untapped in all of us.