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The Nocebo Effect: What Is It? Why Does It Happen?

Lillith has a degree in anthropology which has led her to study how society views and interacts with treatments.

What Can Be Done?

What Can Be Done?

Let’s explore a quick hypothetical situation. You are going in for routine surgery, and your doctor does their due-diligence spiel and lets you know, “Look, it’s a surgery we do every day, but naturally, there are risks associated with any intrusive procedure…”. They then, in true auctioneer fashion, give you the run down on all possible complications (we’re talking anything from fever to blue urine to vanishing fingerprints) that may arise pre/during/post-operation, a good-natured pat on the knee, and quickly darts to the next patient, leaving you to discern his medical speak and prepare for what could conceivably, but by no means necessarily, happen.

Now, you may be one of two people here: either you blatantly trust that you will succumb to at least one, if not all, of the complications the informative doc mentioned, possibly guaranteeing your imminent death, or you offer a shrug, mutter “Miss me with those side-effects,” and head towards the nearest Chick-fil-A to tuck away a spicy chicken sammy, completely nonplussed.

If you are of the former camp and double-down on your belief that harm will befall you, you may end up experiencing unfavorable symptoms, but with no identifiable cause. This phenomenon, lovely readers, is what Doctor Walter P. Kennedy termed the “nocebo effect” some 60 years ago.

“Like placebo effect, but not?” you ask.

Hammer, meet nail. It is exactly like that! But before we delve further into the nuances of nocebo, I’ll drop a quick refresher on the placebo effect.

Manifest That Reality!

During a clinical trial or scientific study, there are generally two groups: a control and an experimental. Now, both groups receive treatment, but only the experimental group’s treatment will contain active agents. The control group will receive an inert drug, also known as a placebo, that has no effect.

Some individuals from the control group will nevertheless perceive improvement.

Why Is This?

Well, scientists aren’t 100% on that front, but a premier consideration is a patient’s cultural makeup, although there is not enough emphasis placed on this element in clinical trials. Depending upon a person’s biocultural diversity, they may have a different perception of “illness,” how health resources should be allocated, the nature of a doctor-patient relationship, and the effectiveness of mainstream medicine. This naturally influences said person’s reality, which, among other things, consists of classical conditioning and expectation. Scientists deem that these are two necessary elements in determining a patient’s response to a placebo.

So, how can classical conditioning be culpable? As an example, imagine you take the same pill each time you have a migraine; over time, you may begin to associate that pill with pain relief. If you are then in a clinical trial for headaches and receive a placebo that looks akin to the migraine pill you already take, you may still experience a lessening of pain because of the association that your brain makes. Your classical conditioning, this habitual process of remedying your headache via an oral tablet, has created an expectation, a conscious belief about some future event.

Is the Placebo Effect a Self-Fulfilling Prophecy?

Are you thinking this is akin to a self-fulfilling prophecy? Well, yeah. 100%. It has been evidenced time and again that participants of clinical trials or scientific studies who are hopeful and expectant of an improved outcome after “treatment” will generally have that belief manifest into reality, albeit unintentionally. They affect their own “treatment” without any conscious awareness of doing so.

The Nuances of Nocebo

The Nuances of Nocebo

So What Is Nocebo?

Adversely, while some people exposed to an inactive drug experience beneficial outcomes, others will endure adverse symptoms that they know might occur if they, in fact, received an active drug. We aren’t talking, “okay, I don’t feel anything, I got the placebo”; we are talking straight-up receiving a placebo and subsequently experiencing new or worsening symptoms.

If an individual has previous knowledge of the pharmacologically active drug, perhaps having responded to it adversely in the past, they may even report reduced efficacy due to their prior experience. Of course, as with the placebo, the likelihood and extent of a nocebo effect unconsciously reflect a person’s cultural conditioning and expectations. Recall the hypothetical intro wherein the side effects were impressed upon the patient? Yeah, that patient is, dependent on the conditions we defined above, statistically more likely to experience those side-effects, especially if a clinician didn’t hold eye contact or initiate physical touch. For some cultures, a hands-off, eye-averting interaction is commonplace, but in other cultures, those subtle cues would indicate something foreboding.

Since medical practitioners are ethically bound to “do no harm,” studies concerning the nocebo effect are greatly limited, because intentionally inducing the nocebo effect could be detrimental to a patient. Nevertheless, I managed to scrounge up a few stats on the matter. Nocebo reactions occur more in people assigned female at birth (AFAB), whereas a placebo effect is split pretty much down the middle between people assigned male at birth (AMAB) and people AFAB. Information collected has also revealed that individuals living with depression and anxiety, a type-A personality, or generally pessimistic in nature are more susceptible to nocebo responses.

psych-snippet-the-nocebo-effect

What Are the Implications of the Nocebo Effect?

Let’s do a reverse hypothetical of the situation with which I introduced the article. You are the doctor now, and a patient you have grown to know fairly well over years of care has qualified for a medical study that could greatly improve his life in the long run. The thing is, the patient has only had you as his doc and is pretty hesitant of receiving treatment outside of your realm of influence. Additionally, he is of the doom-and-gloom variety. You have finally convinced him to join the study, but are now faced with having to impart upon him all the whoopsie-doos that could possibly occur during said treatment.

Do you tell your patient the extent of side effects, knowing he could experience a possible nocebo response, causing him to quit the study that you are certain would markedly improve his quality of life? This is an ethical dilemma that docs deal with on the regular: do I drop the deets on potential complications or side-effects, conceivably causing harm to my patient when my entire credo is based on not causing harm? Do I face the possible ramifications, like a malpractice suit, in failing to disclose? Is it even my right to decide for my patient what he should/shouldn’t be privy? Yeah, it’s a whole thing.

What if your patient is of a diverse ethnic background, and you don’t know how to effectively communicate pertinent information that echoes their experiences and realities, leading to noncompliance in that patient, whose health then only suffers further? What then? Well, although there remains a dearth of research on how to bridge any of the aforementioned gaps, mitigation strategies are evolving.

In the past few years, there has been evidence that mitigation strategies can minimize or even reverse the nocebo effect. Healthcare providers are able to use more encouraging language, along with offering more direct and inclusive communication and educational resources to the patients involved in a study.

The attitude of the medical staff can also have a direct effect; a more caring and empathetic approach coupled with a great awareness of non-verbal cues can contribute to a more positive outcome.

Basically, any bridging of knowledge gaps, clarifying to avoid misconceptions, and consciously working against negative expectations. It seems self-explanatory, but putting that theory into practice remains problematic because of how little an individual’s culture is considered when they agree to a medical study.

The Takeaway

Evidence tracks: thinking more positively about treatments and medicine will boost the likelihood of a better outcome. Mind over matter is, of course, only one part of the process, but it’s one you can control.

References

These sites provided essential information contained above. Check them out for further information on the topic:


This content is accurate and true to the best of the author’s knowledge and is not meant to substitute for formal and individualized advice from a qualified professional.

© 2022 Lilith Eden