Can our training and experience as psychiatrists shed light on vaccine reluctance and the thought process behind it?
I hope to inspire you to apply your understanding of the human psyche to the curious question of people who contract a life-threatening infection because they are reluctant to heed the advice of their doctors and the public health community. An exuberance of irrationality, not mental illness, seems to be at play here. Can our training and experience as psychiatrists shed light on a flawed decision-making process that leads some people to reject caution?
Common self-destructive behaviors can be understood from the perspective of those hypothetical constructs known as immature defense mechanisms.1 However, since the 1990s, the so-called decade of the brain,2 such psychodynamic concepts have receded into the collective unconscious of our profession.3 Instead, I will try to understand our “culture of hesitation”4 by invoking the “nocebo effect”, a pharmacotherapeutic construct carefully studied by clinical researchers who conduct randomized controlled trials of new drugs.4.5
The nocebo effect occurs when individuals receiving inert or effective medical treatment expect the therapeutic intervention to harm them. Just as placebos have the potential to heal, nocebos can cause pain.6 Nowadays, many anticipate and imagine that a potentially life-threatening inoculation is likely to be harmful. The psychic pain generated by this negative expectation can be qualified as an anticipatory nocebo effect, close to anticipatory anxiety.
Regarding COVID-19 vaccinations, Amanzio et al7 establish a link between the vaccine hesitation of European populations and the presence of potent nocebo effects, in particular when individuals are offered specific vaccines whose efficacy is lower than that of the best performing vaccines. These authors go on to suggest that a psychoeducational approach that familiarizes the public with the nocebo counter-therapeutic effect has the potential to overcome vaccine reluctance. Kristensen et al8 describe how potent nocebo effects interfere with the efficacy of biosimilar agents. They suggest that carefully coordinated multidisciplinary communication plans can help overcome negative patient expectations. Most psychiatrists have a lot of experience helping patients with mental illness overcome their reluctance to take psychiatric medication. Sharing our hard-earned wisdom with colleagues from other specialties can be of great benefit.
Bagus et al, in Spain, have written extensively on the relationship between nocebo effects, fear, anxiety and collective hysteria.9 Their view is that the media and governments can inadvertently spread a contagion of fear and anxiety that culminates in a set of pathological beliefs and behaviors akin to mass hysteria. This “infectious” disease of pathological belief systems can spread virally via social media and culminate in a shared anticipatory nocebo effect that can manifest as reluctance to vaccinate.
Ironically, this discussion of nocebos, a relevant concept in today’s world of randomized controlled trials, has led us to retreat into the somewhat retro and uncomfortable territory of misunderstood sociological phenomena like mass hysteria. Psychosocial speculation of this type refers to the expansive and speculative works of Sigmund Freud as Totem and Taboo (1913), Civilization and its discontents (1929), and Moses and monotheism (1939).
Psychiatry, a field once dominated by psychoanalytic theory, has firmly adopted neuroscience, brain chemistry and drug therapy over the past 4 decades. Countless mentally ill people have benefited greatly from advances in biological psychiatry. While we have transcended our mid-20th century love affair with all of the Freudian concepts, it may be important for us to tap into old-fashioned techniques, such as attentive listening, psychosocial formulation, and communication. precise, to help patients and colleagues better cope with this difficult era of pseudo-information and reductionist thinking.ten
1. Vaillant GE. Self defense mechanisms and personality psychopathology. J Abnorm Psychol. 1994; 103 (1): 44-50.
2. Jones EG, Mendell LM. Assess the decade of the brain. Science. 1999; 284 (5415): 739.
3. HT hunting. A collective unconscious rethought: Jung’s archetypal imagination in the light of contemporary psychology and social sciences. J Anal Psychol. 2012; 57 (1): 76-98.
4. Williams S. Public attitudes toward COVID-19 vaccination in children: a qualitative study. medRxiv. Pre-publication posted on July 31, 2021.
5. Data-Franco J, Berk M. The nocebo effect: a guide for clinicians. Aust NZJ Psychiatry. 2013; 47 (7): 617-623.
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8. Kristensen LE, Alten R, Puig L, et al. Non-pharmacological effects of switching drugs: the nocebo effect of switching from an originator drug to a biosimilar agent. BioDrugs. 2018; 32 (5): 397-404.
9. Bagus P, Peña-Ramos JA, Sánchez-Bayón A. COVID-19 and the political economy of mass hysteria. Int J Environ Res Public Health. 2021; 18 (4): 1376.
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