Background: The ability of the mind to anticipate a response to help seems to underly the placebo/nocebo response. Attachment theory clearly outlines internal working models of relationship that predict the usefulness, consistency and indeed potential harmfulness of care.
Aims: Based on an incidental finding in our larger project on depression and coronary heart disease and a reading of the literature we offer the hypothesis that the underlying state of mind with respect to attachment will help explain and potentially predict placebo vs nocebo response.
Method: In our NHMRC-funded study of Mood and Coronary Heart Disease following 105 participants with depression longitudinally, we treated many of these patients with medication and/or psychotherapy. For many we attempted a clinical assessment of the predominant baseline attachment state/s of mind. We found a high prevalence of insecure and especially disorganised attachment states of mind in our group, including many that would be classified as having unstable or incoherent attachment states of mind (“Cannot Classify”).
Results: Within this disorganized group were a small subgroup with a documented nocebo response and for others an anticipated one that made medication unacceptable. A nocebo response in our group was associated with a disorganized/incoherent attachment state of mind.
Conclusions: If replicable, the implications for treatment go beyond the reassurances of pharmacological “no-harm” that Barsky has suggested and may occasionally necessitate drug cessation or withholding until psychotherapy can shift the underlying cognitive set. This model of the nocebo response now requires more rigorous testing.
