Nocebo

 

The Nocebo Effect: How Negative Thoughts Can Harm Your Health

A nocebo effect is said to occur when negative expectations of the patient regarding a treatment cause the treatment to have a more negative effect than it otherwise would have. A detrimental effect on health produced by psychological or psychosomatic factors such as negative expectations of treatment or prognosis.

By Lissa Rankin, MD

Most of us have heard of “the placebo effect,” the heal-inducing effect patients in clinical trials experience when they believe they’re getting a fancy new drug or surgery but are actually getting fake treatment. The placebo effect is real, it works about 18-80% of the time, and it’s not just in your head – it actually dilates bronchi, heals ulcers, makes warts disappear, drops your blood pressure, and even makes bald men who think they’re getting Rogaine to grow hair!

Unwanted Side Effects

But the placebo effect has a shadow side. The same mind-body power that can heal you can also harm you. When patients in double-blinded clinical trials are warned about the side effects they may experience if they’re given the real drug, approximately 25% experience sometimes severe side effects, even when they’re only taking sugar pills.

Those treated with nothing more than placebos often report fatigue, vomiting, muscle weakness, colds, ringing in the ears, taste disturbances, memory disturbances, and other symptoms that shouldn’t result from a sugar pill.

Interestingly, these nocebo complaints aren’t random; they tend to arise in response to the side effect warnings on the actual drug or treatment. The mere suggestion that a patient may experience negative symptoms in response to a medication (or a sugar pill) may be a self-fulfilling prophecy. For example, if you tell a patient treated with a placebo he might experience nausea, he’s likely to feel nauseous. If you suggest that he might get a headache, he may. Patients are given nothing but saline who thought it was chemotherapy actually threw up and lost their hair!

When You Think You’re Going To Die… 

In another study, patients about to undergo surgery who were “convinced” of their impending death were compared to another group of patients who were mere “unusually apprehensive” about death. While the apprehensive bunch fared pretty well, those who were convinced they were going to die usually did.

Similarly, women who believed they were prone to heart disease were four times more likely to die. It’s not because these women had poorer diets, higher blood pressure, higher cholesterol, or stronger family histories than the women who didn’t get heart disease. The only difference between the two groups was their beliefs.

The nocebo effect is probably most obvious in “voodoo death,” when a person is cursed, told they will die, and then dies.  The notion of voodoo death doesn’t just apply to witch doctors in tribal cultures. The literature shows that patients believed to be terminal who are mistakenly informed that they have only a few months to live have died within their given time frame, even when autopsy findings reveal no physiological explanation for the early death.

Dr. Steve’s Story

In response to what I said in my latest TEDx talk about the placebo effect’s evil twin, “the nocebo effect,” L. Chas sent me an email, telling me the story of her brother Steve, who was a physician-diagnosed with the exact same illness that was his specialty. When he was diagnosed with malignant tumors in both lungs, he was told by his doctors that he had five years to live, and knowing what he knew about the disease, Steve believed this.

Exactly 5 years later, to the day, he was snorkeling in Maui when he was found, unconscious on the shore. Steve was resuscitated, but he had been without oxygen to the brain for over four minutes and wound up in a coma until his family chose to withdraw life support.

L. Chas wrote, “More than anything else, I think my brother believed that, when diagnosed with his disease, a patient has ’5 good years left’.  Just as you’ve said in your videos – the nocebo effect. So sad it had to go this way.”

Medical Hexing

Every time your doctor tells you you have an “incurable” illness or that you’ll be on medication for the rest of your life or that you have a 5% five-year survival, they’re essentially cursing you with a form of “medical hexing.” They don’t mean to. They’re not trying to harm you. They know not what they do…

Doctors think they’re telling it to you straight, that you deserve to know, that you should be realistic and make arrangements, if necessary. But when they say such things, they instill in your conscious and subconscious mind a belief that you won’t get well, and as long as the mind holds this negative belief, it becomes a self-fulfilling prophecy. If you believe you’ll never recover, you won’t.

The Moral Of This Story

After reading through the 3500+ case studies documented in the medical literature in the Spontaneous Remission Project, which was compiled by the Institute of Noetic Sciences, I now believe there’s no such thing as an incurable illness. If you or someone you love is suffering from a “chronic,” “incurable,” or “terminal” illness and you want to optimize the chance for spontaneous remission, you have to start by cleansing your mind of any negative beliefs that will sabotage your self-healing efforts. My upcoming book Mind Over Medicine: Scientific Proof That You Can Heal Yourself (which you can now pre-order at Amazon or Barnes and Noble!)  offers tips for how you can change your negative beliefs to positive ones in order to optimize your chances

What Do You Believe? 

Do you believe you’ll be on meds for the rest of your life? Are you resigned to the prognosis your doctor gave you? Or are you motivated to try to activate your body’s innate self-repair mechanisms by shifting your beliefs from negative ones to positive ones?

What is Nocebo?

From Wikipedia, the free encyclopedia

In medicine, a nocebo (Latin for “I shall harm”) is a harmless substance that creates harmful effects in a patient who takes it. The nocebo effect is the negative reaction experienced by a patient who receives a placebo. Conversely, a placebo is an inert substance that creates either a positive response or a negative response in a patient who takes it. The phenomenon in which a placebo creates a positive response in the patient to which it is administered is called the placebo effect.

Both nocebo and placebo effects are entirely psychogenic. Rather than being caused by a biologically active compound in the placebo itself, these reactions result from a patient’s expectations about how the substance will affect him or her. Though they originate exclusively from psychological sources, nocebo effects can be either psychological or physiological.

Etymology

The term nocebo (Latin for “I shall harm”) was chosen by Walter Kennedy, in 1961, to denote the counterpart of one of the more recent applications of the term placebo (Latin for “I shall please”); namely, that of a placebo being a drug that produced a beneficial, healthy, pleasant, or desirable consequence in a subject, as a direct result of that subject’s beliefs and expectations.

Description

W.R. Houston may have been the first to have spoken of a doctor’s deliberate application of harmful “placebo” procedures, as distinct from the other, harmless sort of “placebo” procedures a doctor might apply and whose “usefulness was in direct proportion to the faith that the doctor had and the faith that he was able to inspire in his patients.” Houston (1938, p. 1418) wrote:

… [and while the efficacy of the placebo procedure] is believed in by the doctor, [the placebo procedure itself] is no longer harmless but harmful, sometimes very dangerous. It would seem peculiarly contradictory to speak of the painful and dangerous placebo, yet men are so constituted that they feel the need in dire extremity of resorting to dread measures. Nervous patients in particular, feel that a certain standing and sanction is bestowed upon their maladies when violent therapeutic measures are used.

Houston spoke of three significantly different categories of placebo (pp.1417-1418):

• the drug that the physician knows to be inert, but which the subject believes to be potent;
• the drug which is believed to be potent by both subject and physician, but which later investigation proves to have been totally inert;
• the drug which is believed to be impotent by both subject and physician, but is actually harmful and dangerous, rather than being inert and harmless.

The term “nocebo response” originally meant only an unpredictable and unintentional belief-generated injurious response to an inert procedure, but there is an emerging practice of labeling drugs that produce unpleasant consequences as “nocebo drugs” meaning that the term “nocebo response” may be used to label an intentional, entirely pharmacologically-generated and quite predictably injurious outcome that has ensued from the administration of an active (nocebo) drug.^{[citation needed]}

Anthropologists use the term “nocebo ritual” to describe a procedure, treatment, or ritual that has been performed (or a herbal remedy or medication that has been administered) with malicious intent, by contrast with a placebo procedure or treatment or ritual that is performed with benevolent intent.

Response

In the strictest sense, a nocebo response occurs when a drug trial’s subject’s symptoms are worsened by the administration of an inert, sham,^[1] or dummy (simulator) treatment, called a placebo.

According to current pharmacological knowledge and the current understanding of cause and effect, a placebo contains no chemical (or any other agent) that could possibly cause any of the observed worsenings in the subject’s symptoms. Thus, any change for the worse must be due to some subject-internal factor.

Negative expectations can also cause the analgesic effects of anesthetic medications to be abolished.^[2]

The worsening of the subject’s symptoms or elimination of positive effects is a direct consequence of their exposure to the placebo, but those symptoms have not been chemically generated by the placebo. Because this generation of symptoms entails a complex of “subject-internal” activities, in the strictest sense, we can never speak in terms of simulator-centered “nocebo effects,” but only in terms of subject-centered “nocebo responses.”

Although some attribute nocebo responses (or placebo responses) to a subject’s gullibility, there is no evidence that an individual who manifests a nocebo/placebo response to one treatment will manifest a nocebo/placebo response to any other treatment; i.e., there is no fixed nocebo/placebo-responding trait or propensity.

McGlashan, Evans & Orne (1969, p. 319) found no evidence of what they termed a “placebo personality.” Also, in a carefully designed study, Lasagna, Mosteller, von Felsinger, and Beecher (1954), found that there was no way that any observer could determine, by testing or by interview, which subject would manifest a placebo reaction and which would not.

Experiments have shown that no relationship exists between an individual’s measured hypnotic susceptibility and his/her manifestation of nocebo or placebo responses.^[3]

Causes

The term “nocebo response” was coined in 1961 by Walter Kennedy (he actually spoke of a “nocebo reaction”).

He had observed that another, entirely different and unrelated, and far more recent meaning of the term “placebo” was emerging into far more common usage in the technical literature (see homonym); namely that a “placebo response” (or “placebo reaction”) was a “pleasant” response to a real or sham/dummy treatment (this new and entirely different usage was based on the Latin meaning of the word placebo, “I shall please”).

Kennedy chose the Latin word nocebo (“I shall harm”) because it was the opposite of the Latin word “placebo”, and used it to denote the counterpart of the placebo response: namely, an “unpleasant” response to the application of real or sham treatment.

Kennedy very strongly emphasized that his specific usage of the term “nocebo” did not refer to “the iatrogenic action of drugs”:^[4] in other words, according to Kennedy, there was no such thing as a “nocebo effect”, there was only a “nocebo response”.

He insisted that a nocebo reaction was subject-centered, and he was emphatic that the term nocebo reaction specifically referred to “a quality inherent in the patient rather than in the remedy.”^[4]

Even more significantly, Kennedy also stated that whilst “nocebo reactions do occur [they should never be confused] with true pharmaceutical effects, such as the ringing in the ears caused by quinine“.^[4]

This is strong, clear, and very persuasive evidence that Kennedy was precisely speaking of an outcome that had been totally generated by a subject’s negative expectation of a drug or ritual’s administration; which was the exact counterpart of a placebo response that would have been generated by a subject’s positive expectation.

And, finally, and most definitely, Kennedy was not speaking of an active drug’s unwanted, but pharmacologically predictable negative side-effects (something for which the term nocebo is being increasingly used in current literature).

The ambiguity of medical usage

In a paper,^[5] Stewart-Williams and Podd argue that using the contrasting terms “placebo” and “nocebo” to label inert agents that produce pleasant, health-improving or desirable outcomes, or unpleasant, health-diminishing, or undesirable outcomes (respectively), is extremely counterproductive.

For example, precisely the same inert agents can produce analgesia and hyperalgesia, the first of which, from this definition, would be a placebo, and the second a nocebo.^{[citation needed]}

A second problem is that precisely the same effect, such as immunosuppression, may be quite desirable for a subject with an autoimmune disorder, but be quite undesirable for most other subjects. Thus, in the first case, the effect would be a placebo, and in the second, a nocebo.^{[citation needed]}

A third problem is that the prescriber does not know whether the relevant subjects consider the effects that they experience to be subjectively desirable or undesirable until some time after the drugs have actually been administered.^{[citation needed]}

A fourth problem is that, in cases such as this, precisely the same phenomena are being generated in all of the subjects, and these are being generated by precisely the same drug, which is acting in all of the subjects through precisely the same mechanism. Yet, just because the phenomena in question have been subjectively considered to be desirable to one group, but not the other, the phenomena are now being labeled in two mutually exclusive ways (i.e., placebo and nocebo); and this is giving the false impression that the drug in question has produced two entirely different phenomena.^{[citation needed]}

These sorts of argument produce a strong case that – despite the fact that, in some of its applications, the term “placebo” is used to denote something that pleases (compared with it denoting an inert simulator) – the desirability (placebos nature) or undesirability (nocebo nature) of the phenomena that have been manifested by a subject, after a drug has been administered, should never be part of the definition of what constitutes either “a placebo” or “a placebo response”.^{[citation needed]}

The ambiguity of anthropological usage

Some people maintain that belief kills (e.g., “voodoo death“: Cannon (1942) describes a number of “voodoo deaths” from a variety of different cultures) and belief heals (e.g., faith healing).

A “self-willed” death (due to voodoo hex, evil eye, pointing the bone procedure,^[6], etc.) is an extreme form of a culture-specific syndrome or mass psychogenic illness that produces a particular form of the psychosomatic or psychophysiological disorder that results in a psychogenic death.

Rubel (1964) spoke of “culture-bound” syndromes, which were those “from which members of a particular group claim to suffer and for which their culture provides an etiology, diagnosis, preventive measures, and regimens of healing” (p.268).

It is important to distinguish these “self-willed deaths” from other “self-imposed” sorts of death, such as:

• the “self-inflicted deaths” of suicide, voluntary euthanasia, or the refusal of life-extending treatment;
• the “heroic” “self-inflicted death” of a soldier who throws himself on a hand grenade to save his mates, or that of the Antarctic explorer Captain Lawrence Oates (“I am just going outside and maybe some time”); or
• the “religious self-inflicted death”‘ of the self-immolating suttee, or the more voluntary religiosa (= “voluntary religious death”) of the aged person, whom religious elders have permitted to voluntarily, peacefully, and slowly die by fasting.

Certain anthropologists, such as Robert Hahn and Arthur Kleinman, have extended the placebo/nocebo distinction into this realm in order to allow a distinction to be made between rituals, like faith healing, that are performed in order to heal, cure, or bring benefit (placebo rituals) and others, like “pointing the bone”, that are performed in order to kill, injure or bring harm (nocebo rituals).

As the meaning of the two inter-related and opposing terms has extended, we now find anthropologists speaking, in various contexts, of nocebo or placebo (harmful or helpful) rituals:

• that might entail nocebo or placebo (unpleasant or pleasant) procedures;
• about which subjects might have nocebo or placebo (harmful or beneficial) beliefs;
• that are delivered by operators that might have nocebo or placebo (pathogenic, disease-generating or salutogenic, health-promoting) expectations;
• that are delivered to subjects that might have nocebo or placebo (negative, fearful, despairing or positive, hopeful, confident) expectations about the ritual;
• which are delivered by operators who might have nocebo or placebo (malevolent or benevolent) intentions, in the hope that the rituals will generate nocebo or placebo (lethal, injurious, harmful or restorative, curative, healthy) outcomes;

and, that all of this depends upon the operator’s overall beliefs in the harmful nature of the nocebo ritual or the beneficial nature of the placebo ritual.

Yet, it may become even more terminologically complex; for, as Hahn and Kleinman indicate, there can also be cases where there are paradoxical nocebo outcomes from placebo rituals (e.g. the TGN1412 drug trial^[7][8]), as well as paradoxical placebo outcomes from nocebo rituals (see also unintended consequences).

Writing from his extensive experience of treating cancer (including more than 1,000 melanoma cases) at Sydney Hospital, Milton (1973) warned of the impact of the delivery of a prognosis, and how many of his patients, upon receiving their prognosis, simply turned their face to the wall and died an extremely premature death: “… there is a small group of patients in whom the realization of impending death is a blow so terrible that they are quite unable to adjust to it, and they die rapidly before the malignancy seems to have developed enough to cause death. This problem of self-willed death is in some ways analogous to the death produced in primitive peoples by witchcraft (“Pointing the bone”).” (p.1435)

From Wikipedia, the free encyclopedia

Good link:

https://www.webmd.com/balance/features/is-the-nocebo-effect-hurting-your-health#1

 

 

*Disclaimer: This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider.
Please consult your healthcare provider with any questions or concerns you may have regarding your condition.
The information provided is for educational purposes only and is not intended as diagnosis, treatment, or prescription of any kind. The decision to use, or not to use, any information is the sole responsibility of the reader. These statements are not expressions of legal opinion relative to the scope of practice, medical diagnosis, or medical advice, nor do they represent an endorsement of any product, company, or specific massage therapy technique, modality, or approach. All trademarks, registered trademarks, brand names, registered brand names, logos, and company logos referenced in this post are the property of their owners.