The Nocebo Effect: When Our Thoughts Make Us Physically Ill

By Jonathan Chung, DC

Almost everyone knows about, or has heard of, the placebo effect, the seemingly magical ability for our bodies to feel better or overcome illness from a belief in a treatment that has no specific biological effect.

It’s one of the things in medicine that we are always wary of, especially when selecting treatments associated with alternative medicine. After all, no one wants to waste time, energy, or money on something that isn’t supposed to work. It feels like you’re getting scammed, even when the end result is positive.

However, there is a lesser known effect that I believe is a more harmful phenomenon that isn’t being discussed. It’s more pervasive in the entirety of healthcare, and it’s societal ramifications can have massive implications on outcomes related to your own health.

We’re talking about the Nocebo Effect.

Nocebo, No Bueno

Where positive beliefs about a treatment lead to positive health outcomes in placebos, nocebos occur when negative beliefs about a treatment or condition lead to negative health outcomes.

We don’t really think about nocebos because, in the context of healthcare, we are not really encountering clinicians or practitioners who are intentionally trying to to make us feel worse. It’s just a poor business model.

Nocebos affect us in much more subtle ways. They happen when patients have false or exaggerated beliefs about a treatment, condition, or situation, and these beliefs can often come from well-intentioned providers or social media influencers.

Here are some of the examples of known nocebic responses in society:

• People who think they are sensitive to MSG and feel sick after eating Chinese food with suspected MSG, but feel perfectly fine eating MSG-rich snack foods.
• Patients who take a placebo pill in a drug trial and hear a list of potential side effects are much more likely to experience those side effects compared to patients with no knowledge of any side effects.
• In 1998, a teacher in a Tennessee school reported a “gas-like” smell inside a school. The school was evacuated, and the ensuing panic from a suspected gas leak led to over 100 students and staff going to the emergency room, with 38 of them being hospitalized overnight. It turned out to be a false alarm and no leaks or chemicals were detected. It was considered a mass psychogenic illness.

You may think those people were possibly mentally weak or just faking it, but remember this because it’s super important: People experiencing nocebos are not faking their illness. Their symptoms and experiences are very real, but the cause of their pain or illness is not what they think it is.

Patients with concussion or other forms of brain injury can be affected by nocebos as well. There is a lot of fear about concussion because of the rise of chronic traumatic encephalopathy (CTE). While the overwhelming majority of patients with concussion will recover normally and never have to worry about CTE, we have seen a lot more fear about head injuries in our communities related to this disease. When people have excessive fears about their condition, or too much of their identity gets wrapped up in their condition, the nocebo effect can greatly prolong recovery times.

Are Doctors Creating Nocebos?

One example we see often in chiropractic are beliefs about X-ray or MRI findings. Many patients, after getting X-rays and MRIs, show signs of disc degeneration or disc herniation. Disc herniations, in particular, are known to cause radiating arm and leg pain, especially in the acute phase of injury.

Doctors frequently tell people that they can’t play sports anymore or lift heavy things because they have disc herniations. But there is overwhelming evidence showing disc herniations don’t necessarily cause chronic back pain. In fact, most disc herniations are completely asymptomatic!

By the time we are 50, we will all have disc degeneration, and most of us will have bulging discs, and we will walk, run, and exercise fine without any pain! A large study using MRI on patients without pain showed that common MRI findings associated with pain are present in pain-free people as we age.

But if a patient with a disc herniation has been convinced that their back is weak from herniation and they should avoid exercise, the patient is predisposed to nocebo and one of the best things for the chronic back pain patient . . . exercise!

As clinicians and healthcare providers, we have to be extremely judicious with our words when interacting with patients. We are responsible for knowing when something has life-altering consequences and making the appropriate recommendation for care. On the flip side, we have to be informed and know when a diagnosis is probably self-limiting and allow the patient to feel empowered that they’re going to get better, with or without our help.

Combating Nocebos

None of us are immune to the effects of placebos or nocebos because of the powerful influence that beliefs have on human physiology. Our brains love to create patterns out of noise in order to make sense of the world, and the easiest way to make sense of the world is when our perception matches our beliefs.

It is important to have strategies that reduce the impact of nocebos because nocebos can decrease your ability to recover from chronic pain and illness.

I’ve seen too many patients come into my office who have become so scared of normal human behavior that they may as well cover themselves in bubble wrap. This is no way for a human being to live.

So how do we counter the effects of nocebo? Here are some major factors I’ve seen in practice:

• Never Make Your Diagnosis Your Identity: You would never willingly allow someone to steal your credit card or Social Security card, but you should be even more protective about what you allow to become your identity. When people make their diagnosis their identity, they become resigned to accept all of the possible negative consequences of their diagnosis as an inevitable part of their life.

Embrace the Idea That Your Body Is Resilient: One of the first things we teach patients in our office is that their body is capable of healing itself. Believing that your body is capable of facing challenges and enduring allows someone with a condition or illness to not allow the condition to hold them back.

Don’t Trust Health Providers That Scare You Into Treatment: One of my biggest pet peeves in the world is when I hear other providers use a patient’s condition to scare and coerce them into procedures. I see patients every week whose doctors have told them that a small herniation is a risk for paralysis if they get into another accident and that the only solution is surgery. I’ve also had patients whose chiropractor told them that they had the worst spine they’ve ever seen because they had some signs of age-related disc degeneration on their X-ray.

This. Is. MADNESS.

As healthcare providers, we have to ensure that our words don’t compromise the ability for a patient to get better. When fear and scare tactics are used to coerce people into unnecessary treatment plans, we are not only abusing our patients’ trust for financial gain, we are also compromising the outcomes of patients who simply want to get better.

We have to do better and help all of our patients combat this insidious plague on our patients by empowering people to have faith and confidence in their ability to heal.

Jonathan Chung, DC, is the founder and upper cervical chiropractor at Keystone Chiropractic and Neuroplasticity in Wellington, Florida. Learn more about their cervical vestibular rehabilitation program at www.chiropractickeystone.com