An acronym that explains a lot of things!

A financial publication isn’t a place you might expect to find an insightful article on health, but Financial Times proved the exception. Last weekend, Stuart Blackman explored how seemingly helpful educational health messages can be bad for our health. In fact, they can lead us to believe we are unhealthy and to actually feel quite unwell.

His article, “Why health warnings can be bad,” began by describing the nocebo effect. That’s the powerful phenomenon of developing the most extraordinary physical symptoms when we believe or fear that something is bad for us. It’s the negative stepsister of the placebo effect and the full significance of both isn’t understood by many people. The nocebo effect is behind the confirmation for most food fears, for example. People who’ve been taught to believe certain foods are bad for them actually feel sick, experiencing such things as headaches, chest pain, nausea and indigestion, rashes, cough, congestion, weakness and fatigue, and even paralysis when they believe they’ve eaten them. It’s the stepsister of the placebo effect, at work when we feel healthier after eating foods or taking dietary supplements we believe are healthy.

Even simply reading about scary diseases triggers the nocebo effect, such as the well-known syndrome among students reading medical textbooks who self-diagnose their benign symptoms and become convinced they are sick with exotic diseases. Yet, look how much medical information is on the internet and surrounding all of us in newspapers and magazines today! According to Blackman, research is accumulating that the nocebo effect may be behind a host of 21st century ailments*.

“Some experts are concerned that the situation is being compounded by the efforts of health professionals to raise awareness of threats,” he writes. When we hear that something could be bad for us, has side effects or puts us at risk for health problems, we start looking for signs of illness.

And we’ll probably find some, says [Brian Hughes, a psychologist at the National University of Ireland, Galway], even if the pill is a dummy one or the electric field a sham. That is because unpleasant physical symptoms are a normal part of life for perfectly healthy people. Headaches come and go. Some nights it is hard to get much sleep, and some days it is difficult to keep our eyes open. We might feel light-headed one moment and in a bad mood another. These are all experiences that we would not think twice about were we not looking for signs that things are wrong. But when we are looking, it is easy to interpret a bad night’s sleep as insomnia, tiredness as fatigue, light-headedness as dizzy spells or a bad mood as depression – and then to reattribute those symptoms to whatever it was that we expected to harm us. And once we start believing that something is making us ill, we get anxious, which can itself exacerbate existing symptoms or induce others…

As Arthur Barsky, professor of psychiatry at Harvard Medical School, said, when “you induce negative expectations – whether it’s through a pill, a health warning or advertising by a drug company – you set in motion the same process of symptom reattribution, which then amplifies the symptom, which further solidifies the reattribution.”

According to John Adams, professor emeritus at University College London and Britain’s leading risk expert and author of Risk, a major contributor to our negative expectations is the popular trend among health professionals and health agencies to issue precautionary advice concerning health risks, even when there is no evidence for any credible risk to people’s health. He labeled it a “syndrome” he calls C.R.A.P.

I discovered CRAP recently when I was invited to speak to a conference of psychiatrists. They, like the rest of the medical profession, practice defensively, and labour under incessant demands for the assessment of the risks of everything they do. I boasted that I had found a new mental disorder called compulsive risk assessment disorder. One of them volunteered that the condition I was describing they would call a psychosis - a mental disorder in which contact with reality is lost or highly distorted. Certainly Compulsive Risk Assessment Psychosis produces a more compelling acronym.

As we’ve seen, being surrounded by people, news and information that reinforces our fears about unseen dangers in our food, bodies or exposures can escalate our perceptions of risks, far beyond any credible danger, and let our minds run wild. Soon, we’re afraid of practically everything … and feel increasingly sickly. Thinking too much about health doesn’t make us healthier.

Fear sells

Fear is a well-known marketing technique, yet few people realize how often it’s used. No one profits from quelling fear and giving us the facts that we’re healthier and living longer than ever in the history of humankind.

Fear-based marketing is often presented as health education or health advice. You can tell the difference, though. Once you understand what makes sound science and fair tests of hypotheses, the scare mongering and junk science — “what-if” speculations, biologically implausible arguments, subjective or anecdotal evidence rather than biological/clinical outcomes, flawed and misleading research methodology, and untenable findings — quickly stick out like sore thumbs.

Today, even the normal human condition and our natural diversity is being medicalized. As Dr. Nortin M. Hadler, M.D., professor of Medicine and Microbiology-Immunology at the University of North Carolina, Chapel Hill and rheumatologist, wrote in a recent Journal of Rheumatology:

If questioned closely, nearly all of us can recall low back pain last year, a third of us recall pain at the shoulder, hand or wrist, and 15% of us at the elbow. These memorable episodes last at least a week and often are recurring. Regional musculoskeletal pain is an intermittent and remittent predicament of normal life... These challenges are as much a part of life as heartache, heartburn, headache, and the like.

Yet fear marketing can take advantage of the nocebo effect and use everyday normal aches and pains to frighten people into believing they have real health problems.

Dr. Hadler and professor Adams are not alone in cautioning that health warnings about health risks, including our obsession with health screenings and tests to monitor health risk factors, are teaching people to be patients and leading to growing numbers of those who doctors call “the worried well.” Even healthy little kids are being taught to worry about getting adult diseases of aging. Fat children and adults, for example, live under the constant threat of being told that their size is a death sentence.

Being health conscious versus one of the worried well is an increasingly tenuous distinction. The worried well not only lose their sense of well-being, they seek more tests and visit clinics and doctors more often, accounting for one-third of all primary care visits, and incur healthcare costs 14 times higher than average.

The preventive health movement, concerns over health risk factors, and being inundated by health information has also changed our very concept of what it means to be healthy. We’ve come to believe that we must be continually diligent and get regular medical attention to stay well, rather than realize that most of us are healthy most of the time and only occasionally get sick and then get better again. David Wainwright said: “Health policy is promoting this belief that we’re all at risk from absolutely everything we come into contact with, and that just encourages us to feel more vulnerable and to interpret our normal experiences as health problems. It’s all just amplifying this epidemic of non-specific illness, which has incredibly disabling effects on people.”

It’s not the diseases of aging which actually kill us that are rising — in fact, their rates are dropping and we’re actually freerer from the serious illnesses our grandparents faced. Yet, we are more worried about our health than ever before. As Blackman wrote, the concern of these scientists “is the rise of conditions such as back pain, fibromyalgia (chronic fatigue syndrome) and food allergies, which are characterized by the symptoms expressed rather than by the underlying biology.”

These symptoms may have a biological basis in some individuals and a psychological one in others. So, while rare and tragic deaths resulting from extreme food allergies can be attributed to physiological anaphylactic shock, health warnings on food that “may contain nuts” might be contributing to the rise of food allergies in general, and to the statistics that less than 20 percent of teenagers who believe they have a food allergy actually test positive.

Food labels, product warnings and health information accentuate this focus on fear. “I think it’s become a kind of hysteria,” said Dr. Barsky. And the downfalls are appearing to outweigh the upsides, as people’s confidence in conventional medicine and food production is undermined, which can create its own nocebo effects and lead people to place increasing faith in alternative modalities. If they don’t watch out, wrote Blackman, health professionals and policy makers could find themselves becoming the target of lawsuits over their health warnings “on the grounds that it exacerbates illness through the nocebo effect.” At least, he said, the plaintiffs “would have some scientific evidence to support their claims.”

© 2009 Sandy Szwarc

*Disregarding his example that our body type and weight is under the power of suggestion, sigh...