Is life just a placebo

The nocebo effect

Still unclear: How exactly the nocebo phenomenon comes about

Unintentional negative suggestion or self-fulfilling prophecy: this is how experts explain the nocebo effect, among other things. Doctors and researchers do not yet know exactly what is going on in the body.

The experts certainly have a few explanations for the nocebo phenomenon. One idea is: a patient is given a drug and expects side effects or the symptoms to worsen.

These negative expectations lower the level of endorphins - and less of these so-called happiness hormones in the blood can in fact make the patient feel worse and more sensitive to pain.

At the same time, when the body expects something negative, it sometimes releases the messenger substance cholecystokinin. This is a hormone that acts as a neurotransmitter in the brain and can be involved if a feeling of fear or panic develops.

In addition, studies with brain scans have shown: The pain-processing brain regions are activated - as if the brain felt pain, even if no pain receptors were stimulated.

Nocebo studies would be ethically questionable

And nocebo research is ethically questionable even with sick patients, said the German placebo and nocebo researcher Paul Enck: "You cannot make a patient's symptoms worse by saying, on a trial basis: 'This drug does not help you, it does aggravates your discomfort. '"

There is still a lack of neuroscientific studies. Brain scans and the like could help explain the nocebo effect.

And vice versa, the nocebo effect could help neuroscientists with other research questions: After all, the nocebo effect is a stress factor and therefore well suited, for example, to track down the neurobiology of fear.

What to do with the nocebo effect?

Nocebo effects should be avoided, demands the placebo competence network, to which Paul Enck also belongs. To do this, medical staff would first have to develop more awareness of the nocebo effect - in practices and hospitals, pharmacies and naturopathic centers.

Sayings like "We'll put you to sleep; it'll be over soon" can be funny but misunderstood - especially by anxious people or by patients in extreme situations such as shortly before an operation.

In order to avoid the nocebo effect, doctor-patient communication should therefore take place with a certain rhetorical skill: instead of saying "five percent of patients cannot tolerate this drug", it is better to say: "95 percent tolerate this drug very well Well".

It also makes sense to emphasize the benefits of a drug or therapy rather than explaining any side effects that may occur.

Doctors can even ask their patients if they even want to be informed about every unlikely side effect. Or they explain to the patient what the information on the package insert means: "Very rarely", for example, according to an international convention, means "at most one affected person in 10,000 who use the product".

Doctors' ethical dilemma

If patients do report one or the other undesirable side effect, then both patient and doctor should ask themselves: Are the symptoms a symptom of the disease? Or the symptom of another, perhaps not yet diagnosed disease?

An actual side effect of the drug? Or just a coincidental disorder, because something else is bothering the patient? Or is it actually a nocebo phenomenon?

If the symptoms are due to the nocebo effect, then the doctor can react differently: for example, by explaining to what extent the advantages outweigh the disadvantages. Or he may prescribe a different drug that contains the same active ingredient. Or he can stop the preparation altogether.

Anxiety-relieving medication can sometimes be prescribed to alleviate fear of the medication that is actually needed or its consequences.

In any case, doctors are faced with a dilemma: On the one hand, they are legally obliged to inform their patients about all possible treatments and medications. On the other hand, they should be based on the ancient principle "primum non nocere", in German "first and foremost not harm".

Both principles cannot be fulfilled if comprehensive information can lead to patients having more undesirable side effects or to their symptoms becoming worse.

(First published: 2014. Last update: January 7th, 2020)