The nocebo effect – what is it about? [WE EXPLAIN]

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The doctor had ten minutes for you. He prescribed a drug that you’ve heard is a personality changing chemistry. On the leaflet you read that you will experience memory disturbances, dizziness and hallucinations. AND? You fell victim to the nocebo. We talk with the psychiatrist Dr. Sławomir Murawec about the role of the patient’s attitude.

1. Nocebo means: “I will harm”. The nocebo effect is therefore a situation in which, after taking the drug substance, there is a deterioration, instead of an improvement in the well-being of the person who took the drug.
2. The nocebo effect often occurs in patients who have a bad experience with medical care, do not trust doctors and treat all pharmacological measures with reserve.
3. Psychiatrist Dr. Sławomir Murawiec explains who is particularly exposed to the nocebo effect

Zuzanna Opolska, Medonet: Doctor, a lot is said about the placebo effect, but I have the impression that nowadays we experience the nocebo effect much more often – what is it about?

Dr Sławomir Murawiec, psychiatrist: This is the opposite of the placebo effect, and just as placebo in Latin means “I will like me”, so nocebo means “I will do harm”. So we are talking about a situation in which after taking the drug substance there is a deterioration, instead of an improvement in the well-being of the person who took the drug.

However, this deterioration is not due to a biological effect of the drug. So it is not conditioned by the fact that the drug has a direct negative impact on the functioning of the body – the reason is the negative attitude of the patient to the drug, which causes a deterioration of well-being.

How can this manifest itself? Nausea, headaches, increased heart rate?

All the symptoms you mentioned, plus a long list of others. I would say it largely depends on two factors.

Firstly – from the patient’s own internal fears, and secondly – from the information that comes to him from the outside. If a patient is concerned that they will feel dizzy after taking the medication, they will feel so. If he is worried about his heart – after taking the drug, he begins to feel symptoms in the area of ​​his heart. So, if a person has already had some fear and ideas about the negative effects of the drug, they can become active and result in exactly what they previously feared.

On the other hand, if he reads in the leaflet that nausea may develop during treatment, he is very likely to experience nausea. If a friend of hers has previously mentioned terrible side effects after taking a particular drug, there is a high risk that this person will also experience “terrible” side effects after taking the drug. They can be the same as this friend’s, they can be completely different. What matters is the fear and imagining these effects.

How is thought translated into physiological processes and health?

Jakub Grabowski and Leszek Bidzan wrote in great detail about the neurobiology of the placebo / nocebo effect. It turns out that the mere expectation of improvement by the patient affects not only the increase / decrease of certain neurotransmitters, but also the activity of specific brain centers.

For example, in people suffering from Parkinson’s disease (in which we observe a deficiency of the neurotransmitter dopamine), changes may affect the level of dopamine in areas of the brain that are crucial for the development of degenerative disease of the central nervous system. In depression – changes in the metabolism of the cortical and paralimbic areas, in analgesia – changes in the activity of centers related to the processing and control of pain.

Who among us is more susceptible to the “dark side of the placebo”?

In psychiatry, as in the population, we can describe certain phenomena externally. Thus, women would be more susceptible to the nocebo effect because of their more vivid emotional responses, the chronically ill or those who have previously experienced adverse drug reactions.

On this basis, we can also indicate anxiety patients with a predominant feeling of a strong threat or depressed patients who see everything in black.

Of course, being a psychiatrist, you should always approach similar descriptions with understanding and look at the inside of the patient each time.

From my point of view, the most susceptible to the reverse of a placebo are people with a lot of imagination, that is, in a way “writers and poets”. People who start with a little information or a minor ailment, but their vivid and quick imagination causes a series of negative associations to arise. It begins with information that the drug affects the heart and ends with associations with a heart attack, family extermination, irreversible death, and a total catastrophe.

Could previous negative medical care experiences place us at risk?

Yes, the patient’s experience plays an important role in pharmacotherapy. If the patient has been feeling unwell after a particular drug, taking the same drug or a drug from the same group may increase anxiety, more careful self-observation, and a greater likelihood of nocebo effect.

When prescribing a drug to a patient, I always ask if he has come into contact with a given drug or a given class of drugs. Otherwise, there is always a risk that after receiving the prescription the patient will proverbial “faint” and say: “Jesus … Doctor, not this. My aunt took these pills and she died ”. If this is the case, most often the patient will not put this medicine in their mouths. And even if he swallows it, negative associations and fears will trigger in him. He will start to expect that his condition will worsen, he will start to be afraid, he will listen to himself.

When someone is afraid and listens to the functions of their body, they will surely begin to feel something. Then she interprets it as a side effect and starts to be afraid even more. This is how a vicious cycle of malaise builds up.

So the behavior may give us away – can you recognize patients more susceptible to the nocebo effect?

I could replace a few red flags right away. When I hear the question: Doctor, what are the side effects of this drug? Or: how long will I have to take it? I know right away that the patient has concerns about the possible negative effects of the treatment or would like to take the prescribed drug as short as possible. He is not dominated by hope, such as: I’ll finally get the drug and feel better. On the contrary, he is dominated by anxiety: I will get the pills and I will definitely feel worse.

It is alarming to concentrate the patient’s questions on the side effects that occur even before I indicate a specific drug. The mere fact of referring the conversation to the negative effects of taking the drug, although it is not known yet, indicates that I am dealing with a patient with many fears and prejudices towards therapy.

Perhaps such people require a special approach – for example, educating about the nocebo effect?

I use what I call pre-drug psychotherapy, that is, I talk to the patient about their fears, experiences and associations. Especially to anxiety patients, I explain that it will be very difficult for us to distinguish whether their well-being after swallowing the drug is due to the fact that they are afraid of pharmacotherapy or the fear that they have permanently.

However, I do not communicate directly about the nocebo effect – more in this therapy than in education. This is because these concerns are always very individual. In such a situation, you have to name, say what a specific person has in mind when it comes to ideas about the effects of drugs. Not everyone who is afraid of drugs has a history like I said before, but everyone has a specific, private fear.

At this point, I would say about an important phenomenon.

People who generally trust others in their lives have the experience that people helped them, were caring, and would approach doctors and medications with greater confidence. In turn, people harmed by other people or by fate, full of distrust and fear, will also transfer their distrust to drugs and doctors.

Unfortunately, this is a very difficult mechanism. When someone has had various bad life experiences, for example he was hurt, he does not trust others. If he does not trust, he will approach any situation with just such a distrustful attitude. And then it is very difficult to arouse the feeling that other people, including, for example, a doctor, want to help.

Can the low price of the drug affect the nocebo effect?

It depends again – a patient attached to self-esteem may feel offended by the low price of the drug. He will think: How can a penny medicine help me? If we add that it is a popular drug, used by everyone with a given diagnosis, we practically minimize the chance of improvement.

On the other hand, if the patient is in a difficult financial situation and has depressive thoughts, he will appreciate the inexpensive medicine, recognizing that the doctor really listened to his needs.

Will it be the same for the appearance of the office?

Yes, a low-income person in a luxurious office may feel out of place and even get the impression that the doctor may not understand them. But it also depends on the individual interpretation. If he interprets that he is a very good doctor, it will in turn increase his faith in recovery.

I remember we once talked about how the best placebo was the doctor. Today, trust in physicians is falling practically all over the world, and Dr. Google is becoming a reliable source of information – I wonder if this may affect the incidence of the nocebo effect?

Trust in doctors has been declining and declining for a long time, and I think it’s worth considering why. Like most of my colleagues, I believe it is largely due to the image of healthcare shaped in the media. That is, describing negative phenomena without analyzing the causes that led to them. So we have articles about poor sanitary conditions in institutions, non-compliance with procedures and standards, and doctors’ anesthesia without information about the need for funding for medicine and increasing the availability of treatment.

On the other hand, when a medical protest breaks out, medical errors and negligence are drawn to distract the public. It is about making society think: they demand money, and they make mistakes themselves, they waste money, they have not helped this or that person. It’s true that they probably didn’t help, but why? Maybe they did not have the resources, maybe the lines were too long, maybe there is too little staff?

In my opinion, this has disastrous social consequences – firstly, patients stop seeking medical help, and secondly, the “critical image of the environment” affects the relationship between the patient and the doctor. The patient enters the office with a negative attitude and talks to the doctor with a negative attitude. Even if the appointment goes well, as soon as they leave, they will wonder if the prescribed medication is really working, or if the doctor is on the strip of a pharmaceutical company.

Would a greater emphasis on the doctor-patient relationship minimize the nocebo effect?

Certainly, through open communication, we can enhance the placebo effect. Only when I talk about how I treat during my lectures, I often hear from GPs: everything is fine, but we have ten minutes per patient. For an interview, filling out a card, making a decision and writing a prescription. Unfortunately, we will not be able to improve communication with the patient without increasing the availability of doctors, which means that we are returning to underfunding health care.

After the pandemic, online consultations are becoming more and more popular, can the lack of personal contact with a doctor affect the effectiveness of the therapy?

Indeed, telemedicine has greatly accelerated and many of the existing barriers blocking the functioning of e-health have disappeared practically overnight. Online consultations made it possible to ensure the continuity of healthcare for most patients, but let’s not forget that, according to the Central Statistical Office (GUS), still 13% Polish homes do not have access to the network. Many such people reached me by phone.

On the other hand, teleporting actually impoverishes the contact with the patient by many factors. It can also lead to a greater goal-orientation, i.e. it is no longer a conversation like in the office, but more a matter of getting things done. On the other hand, for some patients who gain trust and show the true “me” it is a big chance.

I even have such experience with a patient in a managerial position, perceived by the environment as a “super strong”. During her visits, she always said that she was a crying person at home and unable to gather together, but it was only Skype calls that allowed me to see the other side of her.

An orthopedist will fix a broken leg, a dentist will treat a sore tooth in a root canal, an ophthalmologist will check our eyesight, select glasses and start seeing. Is psychiatry a field where the risk of nocebo effect may be higher?

Yes, all the studies on the mechanisms of action of drugs to date show that the biological effect of a drug is largely expressed in the context of the patient’s situation and his relationship with the doctor. In other words, it is susceptible to both disturbances – if the relationship and the situation are good, the drug effect will be stronger. In turn, a bad relationship and the negative situation of the patient may cause the effect to be blocked, not to occur, or to cause the nocebo effect. I think that the risk of nocebo is also relatively high in the case of cardiology and oncology.

We are used to the fact that an effective drug should work immediately, but antidepressants do work with a two-week delay. What it comes from?

From the two-phase mechanism of action – in the first phase, antidepressants influence the processing of information of emotional significance, i.e. they correct the black vision of everything characteristic for depression, the so-called gloom. However, this is not a sufficient condition for improvement – the new way of processing information must be experienced in relationships with other people, which allows for the acquisition of positive experiences.

Of course, there are times when patients drop out of treatment for various reasons – some fear that antidepressants will change their personality, others expect improvement after taking a pill or two.

Antidepressant treatment also puts people who are used to being independent in a conflict situation. I myself remember a patient who, knowing that the effect of the drug appeared after about two weeks of taking it, stopped taking the pills after twelve days. He was so afraid of losing his own autonomy. This shows that the effect of the drug is one thing and that the patient’s attitude is another. The occurrence of both premises gives a great chance of success, otherwise we have a nocebo effect.

This may interest you:

1. Placebo and nocebo – how does it work if it doesn’t work?
2. What side effects can medications have?
3. Beata works thanks to medications, so she probably won’t stop taking them until she retires

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