You’ve heard of Placebo Effect, but what about Nocebo Effect?

Dr Jess discusses the true power of the mind - can we heal and harm ourselves?

The human mind is fascinating, exciting, complex and capable of extraordinary feats that we are only beginning to understand (and we rarely talk about).

For so long now, we have been so obsessed with the medical model of mental health and the brain, that we have purposely ignored exceptional things that our mind can do.

Most people have heard the term ‘placebo effect’ (even if they don’t understand it fully) - but I rarely meet another person, even professionals, who have heard of the ‘Nocebo effect’.

Have you heard of the Nocebo effect?

Placebo and Nocebo are extremely important concepts, and so I want to use this article to teach you all about them - and how they apply to our trauma, psychology, psychiatry, and mental health.

Ready?

Okay, let’s go.

Both terms derive from Latin, with "placebo" meaning "I will please" and "nocebo" meaning "I will harm." Therefore, placebo is generally a positive effect, and Nocebo is generally a negative effect - both totally created by the mind, which has a powerful role in shaping our health and our lives.

What is the Placebo Effect?

The placebo effect occurs when a person experiences a positive health outcome after receiving a treatment that has no therapeutic or medicinal value. A classic example involves patients being given sugar pills or saline injections in clinical trials who report improvements in their symptoms despite the fact that these treatments have no active medical ingredient. This is a very common method in psychiatric medication trials, which are often tested against placebo (and oftentimes, the placebo outperforms the medication). The key to the placebo effect is the patient’s belief or expectation that the treatment will work. They are given a sugar pill or saline solution, but they believe that are (or may) being given a medication. Their mind therefore, triggers a healing response based on the anticipation of a positive outcome - despite their being no change to their body, and no medication given.

Placebo effect has been shown to improve everything from Parkinson’s Disease through to schizophrenia, depression through to side effects from chemotherapy.

Amazing, huh?

What is the Nocebo Effect?

On the opposite side of the coin, we have the nocebo effect. While the placebo effect is associated with positive outcomes, the nocebo effect occurs when a person experiences negative health outcomes after being exposed to a completely neutral or harmless substance or situation (imagine the sugar pills from earlier). In this case, the person’s expectation of harm, illness or discomfort actually leads to real harm, illness or discomfort symptoms.

A simple example of the nocebo effect would be if a patient, after being told about the potential side effects of a medication (even though they received a placebo sugar pill or saline solution), begins to experience side effects - such as headaches, nausea, or dizziness - despite receiving no active drug. Just as positive expectations can trigger healing, negative expectations can manifest as real physical distress and illness.

A great example of Nocebo effect is an interesting study I came across a couple of years ago. A large group of men were given a neutral medication. Half were told that erectile dysfunction was a common side effect of the ‘medication’ - and half were not told anything about erectile dysfunction as a side effect.

Of course, none of them would be actually experiencing a side effect, as none of them were taking an active substance.

Amazingly, in the group who were told about erectile dysfunction being a possible side effect, over half of the men (52%) reported ongoing erectile dysfunction versus only 3% of the control group.

So what caused all these guys to stop being able to get an erection?

Just the power of their own mind?

Many strange and extreme medical events have been attributed to the nocebo effect, including deaths.

One reported case from the 1970s describes a cancer patient who died after being told he had three months to live, only for it to be discovered at autopsy that the stage of his cancer had been totally misdiagnosed and could not have been the cause of death. The suggestion of the severity of his illness caused him to die, and yet, no cause of death could be established. Weird.

A more recent case documented a young man taking part in a clinical trial for antidepressants. During the trial in 2007, he overdosed on 29 capsules, collapsed, and needed to be admitted to hospital for severe symptoms including severe hypotension. He believed (and all doctors believed) he had taken 29 antidepressants - but his severe symptoms were rapidly reversed when it was revealed to him and to the doctors that unbeknownst to him, he had been taking the placebo drug all along.

So what caused his severe blood pressure drop? What caused him to collapse? What caused his other severe overdose symptoms?

His mind.

The nocebo effect, just like the placebo effect, is tied to the brain's powerful influence over the body. When a person expects pain or discomfort, their brain can literally cause those outcomes. Not only do we rarely talk about Nocebo effect, but we know very little about how it works.

What we can definitely say though, is that Nocebo effect shows how negative expectations, beliefs, or fears can create self-fulfilling prophecies in our health and our well-being.

For me as a psychologist and as someone who has an interest in trauma and pathologisation, this has totally captured my imagination.

So many questions have whizzed around in my mind for years now.

What happens when we tell people they are ‘mentally ill’?

What happens when we tell people they have lifelong ‘personality disorders’?

What happens if we tell them that there is no cure to their ‘mental disorder’?

What happens when we tell people their mental distress is ‘genetic’?

Hopefully, you can see where I am going with this…

Whilst the placebo effect is the expectation of a positive effect causing a positive outcome, nocebo effect is driven by negative expectations, where patients anticipate harm, discomfort, or adverse effects - and then their brain creates it. Therefore, nocebo effect results in actual physical or psychological deterioration, discomfort, or pain, even when no harmful agent is present and nothing external could possibly be causing it.

Doesn’t this demonstrate the true power of the mind?

If we believe that something bad will happen to us, we create that reality - but if we believe that something good will happen to us, we also create that reality?

Mind. Blowing. Shit.

Limitless. Capabilities.

The Role of Placebo and Nocebo Effects in Mental Health and Psychiatry

Mental health and psychiatry are fields where the placebo and nocebo effects can have profound, life-changing, life-saving and let’s be clear here: life-ending implications.

The power of belief, expectation, and suggestion can significantly influence patient outcomes. While the placebo effect has been shown to improve symptoms in a range of ‘mental disorders’, such as depression and anxiety disorders, the nocebo effect can also be particularly detrimental when it comes to the way mental disorders are framed, especially in discussions about lifelong or chronic disorders.

In mental health and psychiatry, the placebo effect plays a significant role, often leading to symptom improvement even when patients receive treatments with no active ingredients, such as sugar pills or sham therapies. Research has repeatedly demonstrated that the placebo effect is particularly strong in the treatment of depression, anxiety, and other so-called mood disorders. In fact, many clinical trials for antidepressants have shown that a substantial percentage of patients experience a reduction in symptoms simply by believing they are receiving a treatment that will help them.

Most recently, and importantly, scientists analysed data of over 73,000 participants of antidepressant trials and found that over 85% of participants who took the placebo pills reported significantly improved well-being - even outperforming the participants who were given the real antidepressants (Stone et al. 2022).

So what caused tens of thousands of people to feel much better from taking a sugar pill once per day?

Placebo effect. Expectation. Validation.

This effect supposedly occurs because the brain, influenced by positive expectations, can alter its neurochemical activity. This is highly debated, but no matter what the explanation - one thing is sure - the mind is creating its reality based on expectation.

The person believes they are taking a medication, and so they experience all the improvements and none of the side effects (as they are taking a sugar pill). No dry mouth, no dizziness, no headaches, no impact on their sex drive (all commonly caused by antidepressants) - just feeling better.

The Nocebo Effect and Mental Health: Lifelong Diagnoses

On the flip side, the nocebo effect in mental health can be deeply harmful - and even dangerous, especially when it comes to the way patients are talked to about their diagnoses. One of the most troubling areas where the nocebo effect manifests in psychiatry is the communication and narratives around ‘lifelong’ or ‘chronic mental health disorders’. When people are told that they have a lifelong or incurable mental illness, such as depression, personality disorder, bipolar disorder, or schizophrenia, the expectation of a lifelong struggle can worsen their symptoms and hinder their ability to ever recover.

This nocebo effect can occur when patients internalise and believe the message that their so-called ‘mental disorder’ is permanent and that they will always face significant mental health challenges.

The expectation of long-term suffering, combined with the fear of being ‘broken’, ‘mental’, ‘mad’, ‘insane’ or ‘incurable’ will create a sense of hopelessness and powerlessness that exacerbates ‘symptoms’ rather than alleviates them.

Additionally, the nocebo effect in mental health can lead to what is known as ‘diagnostic overshadowing’, where the label of a mental disorder overshadows every other aspect of a person's character and personality, reducing their sense of agency and reinforcing a fixed mindset that they are damaged and defined by their mental disorder diagnosis.

(I am seeing this a LOT online with ADHD, for example).

The false (but powerful) belief that they are destined to live with as ‘mentally ill’ forever can prevent them from ever processing their trauma, seeking or embracing new support, and developing coping strategies that could improve their quality of life tenfold.

What would Jess say?

Seriously, what would I say? I mean. This is absolutely mind bending stuff. Life changing.

I would say that many of our failures, oppression, control, and abuse of millions of people who have been abused and traumatised rests on the power of Placebo and Nocebo.

It’s the Nocebo effect that is causing people to identify with, define themselves by, and then get totally taken over by their ‘diagnosis’. They begin to see themselves as forever damaged and broken - they define themselves as ‘bipolar’ or ‘ADHD’ or ‘depressed’. Their doctors do it to them, and so do their family.

So what is the true impact on their mind and their health, if we look at this through the lens of Nocebo effect?

What happens when we tell traumatised and distressed people that they are mentally ill? Well, it’s likely that they feel worse, feel trapped, and their ‘symptoms’ worsen.

What happens when we tell people that if they ever stop taking their medication, they could harm or kill themselves? How does Nocebo effect play a role here?

Conversely, what would happen if we supported people in trauma and distress without ever suggesting a mental disorder? Without ever talking in lifelong, deterministic ways?

Finally, and probably the most interesting of all my thoughts around this:

What is the true potential of the mind?

If we can create positive outcomes from our expectations, and equally, we can create negative outcomes from our expectations - what can this teach us about life? About our lifespans? Our prognoses? Our responses to trauma and distress?

The messages we give ourselves?

Could the mind be literally capable of healing AND harming the body purely by thought?

Nocebo and placebo effect certainly suggests it can - and rather than being frightened of this revelation - shouldn’t we be excited and amazed by it?

Can we train our minds to alleviate our own health issues? Can we use placebo to safely help people without side effects of dangerous drugs?

Can we stop people suffering by changing the way we talk to them and about them?

What would happen if we all collectively learned how to harness placebo and Nocebo in our own lives?

Where would that leave big pharma, I wonder?

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