Negative Expectations

Andrea Smythe needed something for her depression, but she was leery of medications. Her counselor had recommended trying an antidepressant, and I agreed.

Andrea told me nobody in her family ever took an antidepressant, and none of her friends ever did.

By the time I had dutifully explained about initial nausea, the risk for suicidal ideation and the possibility of inducing a manic episode in undiagnosed bipolar patients, Andrea was squirming in her chair. I didn’t even get to the risk of weight gain and sexual dysfunction before she told me she’d rather do something “natural”.

“Who wouldn’t, after that introduction”, I thought to myself. So we talked about St John’s Wort and other nonprescription alternatives, all less studied but without foreboding government-mandated warnings.

This is the age of informed consent. Anything you don’t say about possible adverse effects can be used against you. That’s why most lawsuits against cigarette manufacturers fail – after all, they warned smokers about the dangers of using their product.

Even when patients agree to take the medication suggested by their physician, the negative expectations can be a hindrance to the beneficial action of the medication – a real nocebo effect. This is the opposite of the placebo effect that some people tend to dismiss as imaginary. Ancient physicians, the fathers of modern medicine and cutting-edge neuro-immunologists all tell us the human body’s ability to heal is helped or hindered by the patient’s state of mind. In many psychiatric diseases this is axiomatic.

I, for one, always look to align my treatment plan with any potentially available placebo force, for lack of a better word.

“Did you ever know anyone who took an antidepressant?” I usually ask. If the answer is yes, I ask which one and how it worked. If the other person is a family member, I not only have a chance for insight into my patient’s positive or negative expectations but also into their genetic predisposition for response or non-response to certain medications.

If the patient believes one medication is more likely to work than another, I would have to feel very strongly about any other medication I might want to suggest in order to pass up all the positive expectations – call it placebo effect if you want – that the patient just offered to the therapeutic situation.

This is where all the practitioners of non-allopathic medicine have several advantages in today’s health care climate; they are not required to warn patients about rare side effects of their treatment, and they are sometimes more able to listen to their patients’ beliefs and preferences without worrying about what insurance companies, managed care organizations or treatment guidelines tell them to do.

The other day I saw a dramatic example of the nocebo effect; Rachel Ruel had been plagued by horrendous attacks of abdominal pain for several years until I started her on a very low dose of metoclopramide, taken only as needed during these attacks. The medication controlled all her dysmotility symptoms and she was finally able to live a normal life. This was long before the 2009 “black box warning” issued by the Food and Drug Administration about the risk for tardive dyskinesia. We talked about the risk for this rare facial movement disorder and Rachel always felt the relief she got from the medication was so significant that she was willing to take the small risk of side effects.

When I last saw Rachel, she had a tooth infection and secondary jaw pain. She had been sure this was the beginning of tardive dyskinesia, so she had not taken metoclopramide at the beginning of her latest attack two days earlier. She was still miserable with abdominal pain. Her unrelated jaw symptoms had escalated her fear of developing tardive dyskinesia, and I was in no position to talk her out of that fear. I had nothing to offer her, except a referral to a university gastroenterologist.

She left my office still fearful and in pain, but she made the least frightening choice she could make in that moment. I am still wondering if I could have handled our visit differently.

1 Response to “Negative Expectations”

  1. 1 Renae Sever October 23, 2012 at 12:51 am

    I am a doctoral student in health psychology, currently trying to figure out my dissertation research project. From what I’ve read here, I am convinced that you and I might have a very fruitful conversation about my topic area of depression care in the primary care setting. Might that be a possibility?

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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