The Nocebo Effect is Serious Medicine

noceboA decade ago I read an intriguing article entitled “The Nocebo Effect: Placebo’s Evil Twin” which argued a patient’s pessimistic attitude could have negative consequences on their health. Research showed that patients who were warned of gastrointestinal side effects from repeated use of aspirin were almost three times as likely to exhibit the side effects as those who were not warned. In the intervening years, I’ve seen other scattered reports that a patient’s anxiety around a disease can lead to a hastened death, even when medicine suggests the patient should recover.

The term nocebo, which is Latin for “I will harm”, was allegedly chosen by Walter Kennedy in 1961 as a reaction to the then recently-coined term placebo.  According to Irving Kirsch, a psychologist at the University of Connecticut,

nocebos often cause a physical effect, but it’s not a physically produced effect.  In many cases [the cause] is an unanswered question.

For obvious reasons, the nocebo effect has not been well-studied: it’s unethical to encourage illness in patients who are not sick.

Science might now be closer to an answer of how to treat the nocebo effect. A recent Oxford University study demonstrates that nocebo pain is detectable in an MRI scanner. This suggests patients are responding to actual pain at a neurological level. A University of Turin study goes one step further by identifying a neurochemical called cholecystokinin which appears to be responsible for this effect. When scientists use drugs to block cholecystokinin, patients do not feel the nocebo pain.

The realness of the nocebo effect makes me to wonder about its impact on doctor-patient relationships. To avoid being sued, doctors might be tempted to emphasize drug side effects to their patients but the mere act of highlighting these side effects might make them more likely to happen. On the other hand, patients who do not completely trust their doctor’s prescriptions might reduce the efficacy of their own treatments. This is the ultimate Catch-22.

While it might seem easy to laugh off, the nocebo effect is clearly real and important to consider in treating patient health. The nocebo effect could even explain how anxiety can cause patients to become worried sick or literally scared to death.

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6 Responses to The Nocebo Effect is Serious Medicine

  1. Jeff Winter December 4, 2011 at 9:42 pm #

    Jonathan, I could not agree more. The mind-body connection is incredibly powerful.

    For the past 20 years, I have suffered from various degrees of neck and back pain. Two / three times / year, I would get the “pinched nerves” in my neck, serious stiffness across my lower back, or sciatica pain. I’d rest, do some physical therapy, and the pain would dissipate after 3-10 days. In August 2010, the pain came and wouldn’t go away. For 3 months, I iced, rested, did physical therapy, didn’t lift my kids, worked on my posture, etc. But nothing worked. Finally, I decided to step things up and got an MRI. Two different neurosurgeons diagnosed me with a “massive” herniated disc in my L4-L5 region (very common diagnosis), showed me the MRI, which clearly showed the herniation, and suggested surgery (micro-discectomy – common, minimally invasive surgery). To try and avoid surgery, one doctor suggested I first try a steroid shot (epidural), which worked great…for 2 weeks. Then out of the blue – back “went out” and I was back to square one.

    During my suffering, I read a lot and spoke to a lot of friends and friends of friends regarding back pain, and came across a Dr. Sarno (based out of New York University – near my office in NYC).

    His theory is a simple, but controversial one: most back and neck pain (and a host of other ailments) are due to stress / tension. The pain is real – no question, but the root cause is NOT structural in nature. That is, the pain is not due to some herniated disc that is pressing on a nerve. Rather, the pain is caused by lack of blood flow, which the body initiates as a result of the stress / tension. It’s sort of the body’s way to distract oneself from dealing with the stress / emotion. It is this lack of blood flow (and thus oxygen) that causes the pain we all feel in our nerves and muscles.

    Sounds wacky? Wait until you hear what I did to fix my back: I read a book. That’s it. No special exercises. No drugs. No cult meetings. I read a book. A book! 3 months later, I have returned to running, throwing my kids n the air, sitting with awful posture, and not a single ounce of pain. How? The simple belief and understanding of what is causing the pain, actually eliminates the pain. Wacky, eh? But true. There is a great example in the book regarding the ulcers. For years, ulcers were near epidemic in the US: everyone had an n uncle or grandfather who had one. After research showed that the root cause of ulcers was stress-related (has since been debunked, but that is very much beside the point), and thus, no longer a mystery, ulcers have been reduced to dramatically. Why? It was simply the KNOWLEDGE of what was causing the ulcers that eliminated them.

    Since gaining “Sarno” religion, I have across many friends / family / acquaintances that have personally benefited from Sarno. And I have been on my own crusade to spread the gospel of this theory and have helped at least 25 myself. Those of you that know me, know that I am not one for tricks or gimmicks. This is real, my friends. If you or anyone you know, suffers from back or neck pain, I could not recommend this book (Healing Back Pain) enough. It literally changed my life and all I did was read it!

    Jeff Winter, Sarno Disciple

  2. Anonymous December 4, 2011 at 11:31 pm #

    Interesting. Since you mentioned doctor-patient interaction, here’s another interesting article:

  3. Bill Wohl December 5, 2011 at 12:27 pm #

    Jonathan, I have a lot of personal experience in this area (the connection between mind and body…).

    For 25+ years, as you know, I’ve been an EMT (emergency medical technician) on my community’s fire company based ambulance. I’ve seen thousands of patients.

    In all those calls, it’s clear to me that patients with a positive outlook — those that have fight and spirit — will always do better, especially fighting long term illness. The atmosphere around those patients — supportive or the alternative not supportive — can influence patient mood, attitude and spirit — and have a huge impact on patient outcome.

    But the most obvious example is this: when a patient, particularly one that is having chest pain, tells you “I feel like I’m going to die” you better be concerned. Those patients “know” what is going to happen…they sense it. And often, they do die.

    Having experienced this several times, I can tell you that the mind has a huge influence on the body’s health.

    And, since you are a student of “managing while walking around,” I can tell you that the “nocebo effect” also applies to the workplace. As I’m sure you will agree, a workplace filled with fun, energy and spirit to win does well. Offices where management wields a heavy hand, where morale is poor, suffer the same “pain” as patients who worry about negative outcomes.


  4. Marcus Starke December 5, 2011 at 5:07 pm #

    Hi Jonathan,
    this is a fascinating topic and I have had several instances within my own family demonstrating the obvious connection between our body and mind.
    I actually believe that modern medicine is obsolete because it almost exclusively focuses on what is rational, can be measured and quantified. The “nocebo effect” is a phenomenon that falls outside the traditional categories and I believe it is a major influencer in our lives, including our professional lives.
    I recently read a very interesting book around a similar topic called “Wisdom of your cells” by Bruce Lipton ( Lipton talks about recent findings that we human beings are not entirely preconditioned by the DNA passed to us by our parents and families but that we are able to influence the 50 trillion cells of which we humans are made of through our will and mind. In other words: people suffer from deseases such as cancer because they believe they will get it since their parents or relatives also had cancer.
    I believe in the absolute power of our minds and that everything is possible, good or bad, if you strongly believe in it.

  5. Rochele HC Hirsch January 14, 2012 at 8:05 am #

    In researching the phenomenon of personal transformation over the last 25 years, I couldn’t agree more with those who recognize that “stress” precipitates illness, accidents, relationship issues, miscommunication, errors, and more. Stress includes emotional stress as well as stress from toxins, allergens, drugs, poor nutrition, insufficient water, not enough rest, etc. — all of which “crunch” your energy. In a nutshell, stress is “not enough flowing, good feeling life energy.” So, along with removing stressors, ANTIDOTES to excessive stress include adding and moving energy through exercise, laughing, meditation, singing, yelling at sports events, hitting balls or pillows, feeling gratitude, journaling … anything that helps you “uncrunch” your life energy.

    Further, I’ve developed a system to rapidly decode the “stress fractals” that recur in our lives — and to transform them. Once transformed, the person’s instinctive reactions to life are different. Clients (and me, too) have dropped cravings, panic attacks and other stressful subconscious self-sabotaging issues. It’s the “stress fractals” that cloud one’s INTENT FOR SUCCESS.

    As a long time Organization Effectiveness consultant, I’m also working with leaders on clearing their intent for success with their organization and their career. I’ve talked with Bruce Lipton, author of “Biology of Belief” and with Luis Angel Diaz, author of “Memory in the Cells.” We all understand that #1 – The underlying stress-producing belief patterns (which are pre-conscious and affect our genes) CAN be transformed and, #2 – Transformation requires going into the “stuck emotion” that holds the pattern in place in order to change the belief. You can’t just “think it different” — that’s coping, not transformation. But better coping can help reduce stress.

    A revolutionary understanding is emerging about how to deal with health issues. And yes, both prevention and healing begins with reduced stress / enhanced energy. Then … there is the transformation option!


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