Nocebo and the Power of the Nocebo Effect

He still wanted the purple pills, he was adamant they worked far better than the far cheaper, non purple generic alternative which were chemically almost exactly the same as the original.  

Most people are already aware of the phenomenon called the placebo effect (placebo from the Latin- I shall please) which is where a patients condition is improved by something fake or relatively inert, the placebo effect can also happen more subjectively for example studies have even shown that large pills work better than small pills, coloured pills work better than white pills, and injections and surgery are subjectively more powerful on a patients outcome than just a pill. People don’t always realise is that there’s a fair amount of medication that we use today can attribute up to half of its efficacy (how well it works) to the placebo effect rather than just drug itself.

This article is all about the counterpart to the placebo effect called the Nocebo effect (nocebo from the Latin- I shall harm), and this is relevant because;

How a treatment is delivered can also negate it’s effect, or cause unwanted side effects and this is what is known as the Nocebo effect.   

I have no doubt that some medications cause unwanted side effects, yet there’s also evidence that telling patients of these side effects can make them statistically more likely to happen, which doesn’t really help the patient get the true benefit of the treatment they are receiving.

I got a call from a patient yesterday (one who had read the product information leaflet inside the packet) the patient was convinced that they were already getting most of the side effects from a pretty inert drug just a few days into their treatment.

Often the nocebo effect does not cause side effects sometimes it just negates the effect of the treatment, the patient can also play a role in how effective a treatment works. Lets take this a step further imagine someone sitting in their room, fed up, convincing themselves they are never going to get better, dwelling on their problems, their pain and how their treatment will never work, they could be using the nocebo effect to negating the effect of the treatment they are receiving.

The doctor too can also make a difference because they are often unaware of the nocebo effect, and how the use of poor language and negative expressions can effect the patient, using expressions like “this will sting” or “this may hurt” has been proven to sting or hurt more,and you are more likely to move after a “don’t move” than a “stay nice and still”, and if you do move with a needle poking around inside you, you can do some real harm.

I’d even go as far as saying things like “does everything feel ok?” is a far better alternative to “can you feel anything?” when testing if a local anaesthetic has taken effect.

I’ve seen patients given a poor prognosis just give up, convince themselves they are going to die, and do so within weeks like a self full-filling prophesy, where’as I’m sure they could have lasted years with a different mindset, this type of ‘voodoo medicine’ is the nocebo effect taken to extreme, here I say that Clinicians should take heed of the words of Frank Carson and his immortal catchphrase because it’s not a joke “it’s the way I tell ‘em’ that can really make the difference, and this is done by negating nocebo effect by using better language.

So how far should clinicians stretch it without compromising any ethical standards? If a physician can increase the likelihood of a treatment working by a factor of over 30% by promoting the placebo effect and negating the nocebo effect shouldn’t they do just that?

“Well one side effect is that you will feel better, and also have to get on with your life,,, and what else do you think you need to do now to help make that happen”?

The fact is negative beliefs and thoughts (be them conscious or unconscious ones) damage your health, perhaps our immune system really does eavesdrop on our thoughts, and maybe we can negate the effect of stress on the body by having a more positive mindset.

“But in the end I gave him the Purple pills, and the fact that he got what he wanted, and the fact he will pay a lot more for them rather than getting the alternative free on an NHS prescription means they will probably work even better than ever”. 

Further Thoughts and Reading.

Here’s an article from the British medical Journal.

Baruch S Krauss, “This may hurt”: predictions in procedural disclosure may do harm
BMJ. 2015; 350: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707520/

Here’s a review article looking specifically at the nocebo effect.  
Häuser W, Hansen E, Enck P: Nocebo phenomena in medicine: their relevance in everyday clinical practice. Dtsch Arztebl Int 2012; 109(26): 459–65. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707520/