Are you feeling a little ill? Have you feared your sense of smell or taste diminishing? Did you go online to look at the list of COVID-19 symptoms and start to thinking, “Hmm, I think I have some of these.”

This then might be a good time to ponder the “nocebo effect” or what has come to be called the “evil twin” of the placebo effect.

The placebo effect is well known and well documented primarily because of the problem it presents in drug trials. In general, if the people involved in a clinical trial respond as well to taking a sugar pill as to the drug being tested, the drug is judged ineffective.

But it’s not quite that simple, as the Harvard Medical School points out:

“About 20 percent of patients taking a sugar pill in controlled clinical trials of a drug spontaneously report uncomfortable side effects — an even higher percentage if they are asked.”

And then there is this:

“Contagious rumor is another source of nocebo responses.”

Scared sick?

You might be sick if you feel sick, and then again it might be your head playing games with your body.

Science knows this happens even if it still doesn’t know for sure how the placebo effect works, let alone the nocebo effect which wasn’t even identified until 1961 and still sounds a little too much like voodoo.

It is, however, real and since the ’60s has been linked to a long list of symptoms.

Many of the research findings on nocebo have come from those clinical trials which found participants suffering adverse reactions to intentionally fake and inert medications.

“Almost half of patients in the placebo groups within clinical trials experience adverse events (AEs) that are attributed to the drug,” a peer-reviewed study in BMC Research Notes found in 2018. “One in 20 patients in placebo groups drop out due to drug intolerance.”

These would be drug reactions and intolerance suffered by people who are not taking a drug.

“It was…difficult to disentangle different possible causes of AEs within placebo groups,” that meta-analysis concluded. “While our analysis did not reveal any clear trend in AE reports by ascertainment method, it remains possible that the way patients are asked to report AEs could influence what they report. This compounds the problem of distinguishing between effects of negative expectations and the effects of mistakenly attributing routine symptoms to a trial intervention.”

Negative expectations

Negative expectations appear to be as powerful, and as unpredictable, as positive expectations.

Though this was once thought to be all in your head, the medical view on that has changed in recent years.

“Maybe 10 or 15 years ago, [placebo and nocebo] were considered to be magical things that were only in the imagination. Now, with many studies, we know they have a biological basis and you have to take them seriously,” neuroscientist and nocebo investigator Christian Büchel from the University Medical Center, Hamburg-Eppendorf, Germany told The Pharmaceutical Journal, a Royal Pharmaceutical Society publication. 

Studies employing functional magnetic resonance imaging (fMRI) have documented a complex web of neurobiological changes whereby the brain can manipulate what the body feels.

The effects can be amazingly powerful.

The journal General Hospital Psychiatry reported a case in which a 26-year-old man taking part in study of a new antidepressant took 29 inert capsules, “believing he was overdosing on an antidepressant.”

After taking the pills, his blood pressure dropped so low he had to be put on “intravenous (IV) fluids to maintain an adequate blood pressure until the true nature of the capsules was revealed. The adverse symptoms then rapidly abated.”

The power of suggestion applies to a broad range of symptoms.

A 2017, peer-reviewed study of nocebo effects in people being treated for cancer found them reporting “pain, loss of appetite, anxiety, cough, depression, diarrhea, and fatigue” when administered an inert substance.

These same symptoms have been noted in other nocebo studies. Some of the symptoms are similar to those of coronavirus.

“The most common symptoms of COVID-19 are fever, tiredness (ie. fatigue), and dry cough,” according to the World Health Organization. “Some patients may have aches and pains, nasal congestion, runny nose, sore throat or diarrhea. These symptoms are usually mild and begin gradually.”

The most important symptom there is arguably the one most easily confirmed by objective means: a fever.

If you have a fever and a cough, John Hopkins Medicine – which has taken a leading role in tracking the COVID-19 pandemic in the U.S. – suggests you “stay home and call a health care provider.”

Scary as COVID-19 might have been made to sound, most people can recover at home as with the ordinary flu.

“Despite what some media reports imply, the case fatality rate is not the same as – or, probably, even similar to the infection fatality rate (IFR),” as the University of Oxford-entity Our World in Data reports.

Inadequate testing and what is now known to be a significant number of people who are stricken with COVID-19 but show no symptoms has left epidemiologists struggling to calculate an IFR that provides some idea of what your realistic odds of survival if you come down with the disease.

“What we do know is that the mortality risk is higher for older populations and those with underlying health conditions such as cardiovascular disease, diabetes and respiratory disease,” World Data adds.

This is the main reason for the current hunker strategy. All medical authorities stress the need for potential COVID-19 carriers to avoid others so as to avoid spreading the illness to the most vulnerable among us. Those with serious signs of coronavirus illness – for instance, a fever – have been asked to take even more extreme precautions.

“If your symptoms are severe or you feel like you need medical care,” John Hopkins says, “call before you go to a doctor’s office, urgent care center or emergency room (and) describe your symptoms over the phone.”

They will advise you what to do next.

Be wary of hospitals

Researchers have suggested one of the reasons for the high COVID-19 death rate in Italy stemmed from the country directing COVID-19 sufferers to hospitals.

When Azabu Insights, a Japanese healthcare and business consultancy, went looking for an explanation as to why the 8.3 percent mortality rate for confirmed COVID-19 cases in Italy was so much higher than the 1.1 percent rate in South Korea, what it found was that the Koreans were sending suspected COVID-19 cases to infectious disease centers while the Italians were letting them into the hospital.

The problem was similar in Wuhan, China where COVID-19 is believed to have originated.

“A study of 138 patients in Wuhan, China, suggests 41 percent of patients may have been victims of hospital-related transmission. This further suggests to us that hospitals are perhaps the worst place to be during a viral epidemic,” the study said.

The son of the first Alaskan whose death has been linked to COVID-19, told public radio station KFSK in Petersburg, that he believes his father – 76-year-old Pete Erickson – contracted the disease after being medevaced from the Panhandle community to Virginia Mason Hospital in Seattle in late February suffering from other serious health problems.

“He had congestive heart failure,” said son, Pete Jr., and his lungs and kidneys were failing.

“The doctors that were taking care of him didn’t suspect (COVID-19). Everybody that was working on his case that was familiar with what he had been going through, they never thought for a second that this was what happened. What it took was another doctor to come in.”

That doctor asked if Pete Sr. had been tested for COVID-19. The other doctors, Pete Jr. said, responded with, ‘No, why would we look at that?'”

As it turned out, Peter Sr. had the disease. So does Pete Jr. who is asymptomatic and self-quarantining. He reported “maybe just little bit of sinus pressure. No cough. No fever. Nothing like that. Nothing that has commonly been an indicator of it.”

The asymptomatic cases and the ease with which the disease is transmitted in hospitals is what is causing problems in containing the pandemic.

“In past outbreaks such as SARS, cases of asymptomatic spread were low and in-hospital spread was considered controllable through the use of masks and other standard procedures,” the Azabu Insights report noted. “In the case of coronavirus, however, we see clear evidence of both asymptomatic spread and spread from within the hospital system….We believe the role of asymptomatic spread and from spread within the hospital system remains significantly underestimated.

“China and Korea have adapted quickly and changed how they approach the management of this pandemic. In particular, they have shown that aggressive isolation of patients from the regular hospital system, including preventing congregations at test centers and separating coronavirus patients from regular patients in completely separate hospitals, can be an effective tool in controlling the spread of the coronavirus.”

The study suggested all countries should follow the lead of Korea and China. Hospitals in Alaska have now been closed to visitors and COVID-19 patients are being segregated.

The closure has not been popular with the relatives of the sick, but medical authorities are in agreement it is the wise thing to do.

The notice from the Providence Health & Services Alaska