Jerome Groopman, MD, in his recently published book, How Doctors Think,1 discusses cognitive errors that can lead physicians to misdiagnosis and mismanagement of patients. Several of these cognitive errors readily apply in the case of Ménière’s disease. Attribution errors occur when patients fit a negative stereotype. The negative stereotype of a neurotic patient with Ménière’s disease can lead physicians down the path of inactive management or incorrect diagnosis. Additionally, personality characteristics and comorbid psychiatric disease can compound the issue. When the patients don’t improve with standard medical therapy, this leads to physician frustration and, often, blaming the patient. There appear to be three main factors that cloud this issue: (1) the specter of malingering or symptom magnification, (2) reported placebo effect in trials of treatments for Ménière’s disease, and (3) concomitant psychiatric disorders.
Explore This IssueJanuary 2008
Among patients with potential for secondary gain, malingering is quite prevalent. As we published previously,2 76% of patients complaining of dizziness with potential for secondary gain (defined as patients with pending lawsuits, workers’ compensation claims, or disability claims) demonstrated nonphysiologic posturography results strongly suggesting malingering or symptom magnification. However, among those without any obvious potential secondary gain, malingering and symptom magnification seem to be quite uncommon. Nonphysiologic posturography results in that same study for these patients was only 8% (and the nonphysiologic results were of a much milder magnitude). Yes, there are somatosizers among vestibular patients. However, even the nonphysiologic results found in the nonsecondary gain group were more suggestive of symptom magnification rather than outright malingering. So, unless there is reason for secondary gain, malingering is very rare.
The placebo effect is defined as the therapeutic and healing effects of inert medicines and/or ritualistic or faith-healing manipulations. In no other disease process treated by otolaryngologists has the placebo effect been so emphasized as in Ménière’s disease. This is probably because of our poor understanding of Ménière’s, but also because there is a long-standing bias that Ménière’s disease is psychogenic in nature.
A study by Hrobjartsson and Gotzsche published in the New England Journal of Medicine in 2001 regarding the placebo effect failed to show any demonstrable effects for placebo.3 In a systematic review of 130 trials with patients randomly assigned to either placebo or no-treatment groups, they found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. In other words, when using objective measurement outcomes, placebo was no different from no treatment (i.e., there was no placebo effect).