Placebo and the lesser know evil twin nocebo

October 29, 2018


The placebo effect has been in the media quite a lot recently, and I often hear people wonder whether the effects of a particular treatment are ‘just placebo’.  So, what is actually happening, and does it matter if it is ‘just’ the placebo effect?If your health problem improves after receiving a treatment, there are three reasons why this may have happened.  1. The treatment you received was effective and has addressed whatever health problem you had.  2.  Your health problem got better naturally and would have done so anyway, even if you had not received the treatment.  3. The placebo effect.  This is where our belief in the effectiveness of the treatment is responsible for the improvement, rather than the treatment itself.  In reality, any improvement we see after receiving treatment for a particular condition is probably a combination of all three of these reasons.  The way the placebo effect works is complicated, but essentially involves changes in our brain physiology.  It is more than simply being tricked though, as the placebo effect can occur even when the patient knows the treatment is a placebo!  It has also been suggested that the placebo effect doesn’t really exist at all.  It is simply that some treatments work in a different way than we expected.  Consequently, as our understanding improves regarding the many complex interactions that take place during a patient’s treatment, the placebo effect may become less of a concern.   

The placebo effect has been studied a lot in relation to pain, and what we know is that our experiences of pain generally follow our expectations.  For example, if we are given a tablet and told it will reduce our pain, we have been conditioned to expect our pain to reduce, and this will often happen even if the tablet doesn’t actually contain any medication (a placebo drug).  Unfortunately, placebo has an evil twin, known as nocebo, which works in a similar way but has the opposite effect.  For example, in research experiments, when an individual is told that a very painful electric shock will be applied to them, they will consistently rate that shock as being much more painful than individuals who were told they will only receive a mild electric shock – even when both are receiving the same intensity of electric shock.  Here, the first person is being verbally conditioned to expect more pain, which will normally result in them actually experiencing more pain. 

So, why is this important?  The key to placebo and nocebo is that our expectations of pain will influence our experiences of pain.  Because our level of pain is only very loosely connected to what is actually wrong with us, if something reduces our pain, it doesn’t matter how, it’s always good news.  What is more important, is the nocebo effect.  The nocebo effect can make our pain worse and it can even prevent us from recovering at all.  It is also very common and worse still, it is often caused by the very healthcare professionals that we have sought to help us.  Nocebo effects most commonly occur because of the language used by otherwise well-meaning health care professionals when discussing a problem with a patient.  Terms such as: you have a disk that has slipped; you have torn your ligaments; you have a bone out of place; your cartilage has worn away; you have the joints of an 80-year-old; you have wear and tear; can all cause the nocebo effect.  Such terms create a sense of structural and irreparable damage in our bodies, which then conditions us to expect more pain and reduces our expectations of a normal recovery.  Receiving x-ray and MRI scan results that reveal similarly alarming details can also have the same negative effect on our recovery.       

Ligament tears, disk bulges, worn cartilage and all these other horrible sounding things are almost just as common in people without pain as those with pain, so we can’t always blame them for causing the pain, even if we can see them on a scan.  Instead, we should focus on the positives, things that we know can improve the situation, strategies for managing pain, techniques for returning to activity, different ways of exercising safely, and treatments that we know can work.  This is what we try to do at City Osteopaths.  We won’t dwell on what may or may not be damaged, we focus on making sure treatment is safe and then developing strategies for getting you back to what you want to be doing as soon as possible. 

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