‘The placebo effect should be discussed in the doctor’s office’

Prof. dr. Dr. Andrea Evers, professor of health psychology at Leiden University and scientific director of the Department of Psychology, is researching the placebo effect, among other things. She talks about its uses in practice and the benefits it can provide.

Psychoneurobiological influences on health and disease cover a wide field, says Evers. These are questions such as’ Do stressors play a role in illness? If so, what role? Can lifestyle protect against chronic diseases? ‘. ” Evers is working on this in Leiden as well as in Delft and Rotterdam to stimulate interdisciplinary collaboration between different disciplines. “You can’t solve that kind of problem by becoming one place within your own discipline,” Evers says. “For this, bridges must be built that not only have a scientific basis, but are also based on contacts with other social partners and in collaboration with patients.” For example, Evers has a job at the Faculty of Industrial Design in Delft. “We use many e-health applications to support patients. This ranges from apps and e-coaching to serious games and virtual reality.” According to Evers, it is really about everything where technology can help to promote the well-being of the citizen. “I use the word ‘well-being’ consciously because it is more than just physical health and includes psychological and social aspects.” A good example of a direct application of interdisciplinary collaboration is the use of a virtual reality tool in research into the placebo effect. “This allows young doctors and nurses to receive virtual feedback from patients who respond to (non-) verbal signals. With the placebo effect, the relationship between doctor and patient is very important, and they learn to optimize it.” In addition, it is also possible to learn to explain the nocebo effect correctly, by Evers. “If patients are very afraid of side effects from drugs, they increase the chance that they will actually develop side effects by constantly worrying about them. You can try to reduce this by first telling us something in simple language about the nocebo effect and that it can have an impact. ”

Placebo effect is expectation effect

Placebo research is one of Evers’ basic lines of research. “We look at the placebo effect as a psychological learning mechanism. What does it mean that something that in itself has no active ingredient, nevertheless has certain effects on our well-being in a broad sense (physiological and psychological), purely in terms of expectations? This is based on learning processes that we can analyze. ” Evers explains that the placebo effect is an expectation effect that plays a role in any treatment. “This is not a substance that does not contain anything, but all ordinary treatments that are used where the placebo effect has a large proportion. This is almost always based on a positive expectation. The learning effects that play a role in the placebo effect are based on a number of mechanisms. First of all, the information we get about something, for example that it would work really well, is important for the image. The second mechanism, conditioning, is the most important. Verbal suggestion and other elements work only because one has a certain expectation from the past that something has meaning or quality. Suppose Prof. Scherder says something, then you believe him much faster than when the immune neighbor says it. We have conditional expectations that are determined for life by our culture and upbringing. The interesting thing is that this process produces all kinds of physiological effects. “Evers illustrates this with an example.” Like you have experienced many traumas in, for example, a hospital. Then you get a negative effect and a stress reaction every time you come back on a hospital. It’s actually a nocebo effect. ” According to Evers, there may also be a generalization of an older condition, she gives an example from clinical practice: “In children with arthritis who are treated with methotrexate, we see that some become very nauseous. Very often they develop aversive reactions. is expressed in the way that if they receive methotrexate on Tuesday, they already get nausea on Monday.This can only be explained by a conditioning mechanism.However, for some children it goes much further.The methotrexate pills are yellow and these children react to “Everything is yellow with a scream. Also on a yellow ball, or something else that actually has a positive appearance. It is a typical generalization. For example, it also creates an anxiety disorder, and it can be very serious.”

Application in practice

The placebo effect can very easily be used in a hospital, says Evers. “If patients are given a pain medication and know it, they will experience much less pain than if they do not know it.” The opposite effect of the placebo effect, the nocebo effect, also provides interesting data. “That study started when it was investigated how many side effects patients in control groups who had not received treatment reported. It turned out that they reported just as many side effects and also just exactly the side effects listed in the package leaflet. It was actually not possible because they had not been given an active ingredient. It has everything to do with how we think we should inform people about side effects, in detail, and thereby create a kind of boomerang effect that actually makes them have more side effects. ” It is also known that when certain (new) conditions are widely discussed (‘hyped’) in the media, this can also lead to a ‘tsunami’ of unwanted effects and side effects. “It is therefore difficult for the government to communicate in the right way,” Evers says. “On the one hand, the seriousness must be emphasized, but on the other hand, people do not want to scare people and ‘evoke’ all sorts of unwanted effects. So you have to think very carefully about what exactly is communicated in the media. ”

What information?

It appears that the desired controlled supply of information is contrary to shared decision making (SDM). Although SDM is a ‘hot topic’ in medicine and is often cited or used, according to Evers, it is certainly not an ideal model for all patients. “It is important that patients are first informed about the placebo and nocebo effects. It is not at all a topic of discussion in the consultation room. However, looking at the extent to which it contributes to the effectiveness of the interventions, it is worrying that we continue to pretend that the effect is solely due to the medicine alone. And that while every doctor knows that the placebo and nocebo effects play a big role in everything they do, and it does not matter how something is prescribed and what is told. In addition, I think the choice should be left to the patient to what extent he or she wants to participate in the decision-making process and what he or she wants to know. Not everyone needs super-detailed explanations of a treatment or intervention, while for others it is essential to prepare as best as possible and be reassured. The dissemination of information must therefore be tailored to the individual level. ” Evers argues for making the information available on a website, especially with regard to risks and side effects, so that patients can access them and decide for themselves whether they request this information.

Effects on the immune system

Evers and her research team were one of the first to show that the placebo effect works just as well against itching as against pain. “For example, if you first get an antihistamine and then a placebo, it turns out that the same immune response occurs. Although not at the same intensity, there is a clear simulation of the effect on medication as previously found. Thus, physiological processes are affected by conditioning. “Evers states that this knowledge can be used at three levels: at the patient level, in communication and with medicine.” In the first case, patients can be mainly focused on the goal they are pursuing with an operation, for example, working or playing with their children. This goal leads to a better recovery after the operation. Secondly, trust in doctor-patient communication is the most important component in the placebo effect. The relationship with the patient is very crucial and here openness plays a role. Practitioners “to be honest: exaggerating effects is not useful because patients will not (quickly) be more likely to believe them. It is much stronger, for example, to admit that you do not know. It increases credibility.” Finally, Evers claims that by using the conditioning principle, prescriptions can be made more efficiently. “Now almost always the same dose is given to almost all patients without taking into account the conditioning principle. If you did, you would first give a high dose to wait the conditioning effect and then repeat the conditioning.This is especially interesting for chronic diseases such as psoriasis, depression and ADHD.Studies have shown that one can use medication more effectively in this way.This can be very valuable, especially when one has to reduce chronic “There are only about 20 studies in this area worldwide, so there is a clear need for more research into this.”

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