Is your clinician making you sicker than you need be?

Updated: May 1, 2019

Most people have heard about the placebo effect whereby a person feels a beneficial reduction in illness symptoms when given a fake drug that they think is real but many people are unaware that there is an opposite effect called the nocebo effect.

Every clinical drug trial now randomly assigns patients to either a real drug, or an alternative in the form of an inert pill or ‘placebo’. The patient doesn’t know which they are taking but even those taking the placebo can tend to show some improvement – thanks to their faith in the treatment. This is commonly known as the ‘placebo effect’. Yet alongside the benefits, people taking placebos often report puzzling side effects like nausea, headaches, or pain – that are unlikely to come from a placebo because it is in effect a sugar pill with no therapeutic properties.

The problem is that people in a clinical drug trial are given exactly the same health warnings regarding possible side effects whether they are taking the real drug or the placebo. Somehow, the expectation of the side effects associated with the real drug can produce physical symptoms in some placebo takers.

In the same way that voodoo shamans can harm their victims through the power of suggestion, priming someone to think they might experience side effects can sometimes produce the actual symptoms. The likes of vomiting, dizziness and headaches can be triggered through belief alone. It’s called the “nocebo effect”. In medicine, a nocebo is an inert substance or form of therapy that creates harmful effects in a patient. The nocebo effect is the belief induced adverse reaction experienced by a patient who receives such a therapy.

There are strong nocebo effects reported in many treatments for conditions such as headache, multiple sclerosis, and depression. In trials for Parkinson’s disease, as many as 65% of patients reported adverse effects as a result of taking a placebo which was just a sugar pill. As many as one out of 10 participants in drug trials who are being given a placebo will drop out of trials because of the nocebo side effects. Although many of the side effects are somewhat subjective – like nausea or pain – nocebo responses do occasionally show up as rashes and skin complaints, and they are sometimes detectable on physiological tests too. Neurological researcher Dimos Mitsikostas stated, “It’s unbelievable – they are taking sugar pills and when you measure liver enzymes, they are elevated”.

Nocebo responses can, for instance, be brought about by unintended benevolent suggestions on the part of clinicians, e.g., when informing the patient about the possible complications or side effects of a proposed treatment or the expected symptoms associated with a diagnosis. Have you ever read the list of possible side effects on a medication you bought at the pharmacy or were prescribed by your doctor and started to wonder if you were experiencing them? If so, this was possibly the nocebo effect.

Being a manifestation of the mind, I would argue that the nocebo effect is especially potent when we are seeking treatment for troubles with our mind and emotions. Imagine going to your clinician because you have been experiencing problems with your emotions or vitality. You may think you are just a bit stressed or a bit run down and they tell you that you are actually depressed or suffering from another mental illness. Not only are you sicker than you thought but you can’t fix it yourself and need counselling and or medication. This is the unfortunate experience of many people who seek help from mental health services. They are left feeling they are somehow failing as people and the stigma that this produces.

I am not arguing that the clinician is wrong in their diagnosis or recommendation about treatment and would absolutely recommend that you follow their advice, but simply that their diagnosis and or treatment prescription can have a perverse nocebo effect which is especially potent in regard to mental health. If our clinicians are only focused on what is wrong with us and no attention is paid to what is right with us then we may become more susceptible to experiencing the negative symptoms of the condition.

I would argue that many clinicians are as unaware of the nocebo effect as the general public. They often make the presumption that their benevolent intentions to diagnose what is wrong with their patients, offer treatment and warn them of the possible consequences of their condition and treatment are harmless. For this to change clinicians need to have awareness about the possible nocebo effects of their conversations with patients. If clinicians were to deliberately focus as much attention on what is right with someone, their goals, their strengths and the exceptions to their problems then they would run the risk of inducing the more beneficial, placebo effect!

For further thoughts on how the nocebo and placebo effects impact on health care, and how solution focused interactions can be used to promote placebo type responses, see our paper on solution focused recovery at:

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