Nocebo Effect: What It Is And How It Affects People
The placebo effect is a scientific concept of enormous popularity that, perhaps because it is a tremendously curious phenomenon, has become part of colloquial language. For this reason, many people have a rough vision of what it is and what its scope is.
The placebo describes a positive effect on the body after the use of a substance whose chemical properties are really harmless, having become known in particular for its presentation as sugar tablets “disguised” as a real medicine.
The accumulated evidence suggests that they may play a fundamental role in this effect. the person’s beliefs and expectations In this sense, it is understood that the benefit is associated with internal variables whose analysis is essential to understand the individual response to the use of any drug or therapeutic procedure (regardless of its objective impact on the body).
Like many other things in the field of science, there is also an antagonist for the placebo effect: the nocebo effect This article will focus precisely on it, highlighting the nature of a less known but equally interesting reality.
The term nocebo comes from Latin. Its form uses a verbal declension in the future for the verb “nocere”, and its literal translation could be “(I) will harm.” It is, therefore, a phenomenon opposite to that of placebo. This nocebo effect refers to any harm that may occur after the consumption of a substance that in reality lacks “properties” by which to explain it, having to resort to hypotheses in which the contribution of subjective aspects is contemplated. Such harms are often referred to as “harmful,” “undesirable,” or even “dangerous.”
Its description was much later than that of the placebo, with the original references being found in texts from the 1970s, although its definitive conceptual delimitation would have to wait until the early years of the 1980s. The pioneering experiments on the issue made use of fictitious electrical currents to induce supposed “headaches” In this case, the researchers deliberately provided false information to the subjects, making them believe that they would feel such a symptom after its application. Although no shock was ever administered, almost all participants reported experiencing headaches (to some degree) after the trial.
Theoretical models to explain it resort to the role of expectations, as in the case of placebo, but also to classical conditioning and personality variables. The truth is that discovering its nature is important, because sometimes it can hinder the way a person adheres to pharmacological treatments that could lead to a clear improvement in their state of health. For this reason, there have been numerous research projects that have been articulated, during the last decade, to better understand it.
In general, we know that up to 19% of people report negative side effects from using a substance whose chemistry cannot explain them in any way. These are sometimes legal drugs, for which no consequences or harms have been described in the direction pointed out, but which the person expressly perceives (sometimes due to past experiences or incorrect “ideas” regarding its functioning in the body). The effect is more common among women (30%) than men (19%).
Why happens?
The exact mechanisms by which the nocebo effect occurs are still largely unknown , because its study often involves some type of ethical or moral dilemma. This is because it would mean lying to the subject about what is administered to him, and specifically making him believe that he is going to voluntarily expose himself to a dangerous or harmful experimental condition. Because it is necessary for the person to believe in this effect, it would imply the acceptance of self-harming conditions that escape the deontological codes of the research activity.
However, today at least four variables are known to be involved in the appearance of the nocebo effect: personal expectations, classical conditioning, personality dimensions and life experience. In this section we will delve into all of them.
1. Expectation
The value of expectations is essential for the nocebo effect, so that what the subject expects to experience ends up being imposed in reality as a tangible result on his organs and tissues. It is because of that In the study of this phenomenon, it is essential to offer the person information about the “symptom” that you want to elicit , this being false (in the sense that the substance or procedure lacks any effect on your body), but used with an explicit intention to convince the subject of the opposite. It has been contrasted, especially, with allergic responses (pain).
With this, and especially by resorting to an authority figure (the researcher), a solid expectation would be formed with the power to generate the suggested negative effects. For example, it is known that beliefs about the emetic effect of chemotherapy (ability to cause nausea or vomiting) are proportionally related to the occurrence of this unpleasant side effect.
2. Classical conditioning
Classical conditioning has received much credit as one of the procedures on which the possible development of a nocebo effect is based. In this particular case, it would be an association (due to contingency and repetition) of an unconditioned stimulus and a neutral stimulus, the first of which has the capacity to provoke a response in the organism (innate). In this way, through repetitive exposure to situations in which both occur at the same time, the originally neutral stimulus would acquire the property of a conditioned one This means that it would generate effects similar to those caused by the original unconditioned stimulus.
A simple example of this type of nocebo was found in a study in which a group of people were offered a lemon-flavored drink at the same time they were receiving a dose of chemotherapy.
The repeated presentation of this sequence finally caused the lemon soda (neutral stimulus) to be associated with the side effect (nausea) of such treatment (unconditioned stimulus), so that its isolated consumption produced the vomiting response. That is, the lemon would generate this unpleasant sensation in the absence of treatment, therefore becoming a conditioned stimulus. With this process, a nocebo effect would be acquired for safe drinks.
3. Personality factors
It’s known that Some personality traits can contribute substantially to the appearance of the nocebo effect They would, therefore, be tacit elements of mediation between what was previously outlined (expectation and classical conditioning) and its occurrence. Regarding these dimensions, it is now known that pessimistic people (that is, those who repeatedly set dark expectations) are more likely to suffer from the nocebo effect. In the same way, and perhaps as a direct consequence, they do not report the placebo or its benefits in an equivalent way to those who are optimistic (if not much less so).
Likewise, type A personality (which refers to a recurring feeling of pressure and competitiveness as an elementary variable in interpersonal relationships) is also associated with a higher risk of the nocebo effect, when compared to type B (much more “balanced” in time management and social life). The same can be said regarding neuroticism (tendency to worry and experience negative emotions). Thus, it is concluded that pessimism, neuroticism and attitudes that emphasize competitiveness are important to understand the phenomenon.
4. Personal experiences
Finally, a fourth explanatory factor is found in previous life experiences. The fact of having witnessed someone suffer the adverse effects of a drug, or building the anticipation that they will occur after acquiring imprecise knowledge about how they work in the body, is a risk factor associated with learning. All this can be accentuated on the assumption that the original vicarious model from which the expectation was articulated, was someone to whom we have an emotional bond.
Adverse experiences with the health system, as a whole, also precipitate the nocebo effect (as they shape the belief that these professionals are incompetent or that they make invalid judgments). In the event that the treatment is carried out during a forced admission, against the explicit will of the person to whom it is administered, the problem is also significantly aggravated. This last modality is currently the subject of intense controversy, and should only be applied in the event that some potential risk for the person or third parties is suspected.
To avoid the appearance of the undesirable nocebo effect, it is essential to influence the variables susceptible to it, such as the person’s expectations regarding the drug or the interaction that occurs in the therapy space. One of the general recommendations is to give adequate information and do so in a realistic way, emphasizing the closest possible balance to the benefits and harms that all medications have. This is relevant in all intervention contexts, but more so in those that are particularly critical due to the expectations that accompany them (for example chemotherapy, where there are many preconceived ideas about its effects).
It is important to offer information in the most direct and truthful way possible, promoting that the person can actively participate in the treatment they are going to receive , and that the uncertainty regarding it is minimized to the maximum possible. In this way, the subject is able to actively collaborate in their process towards recovery or improvement, and a quality therapeutic bond is stimulated. This form of relationship has been shown to reduce the risk of the nocebo effect, and also stands as the way to increase the person’s satisfaction with the care received.
In short, the objective of the professional should focus on the contextualization of the benefits and secondary aspects of the compound that is going to be used, on the detection and correction of erroneous preconceived ideas, on the search for active collaboration during the decision-making process. decisions, in the appropriate adjustment of expectations and in the construction of human contact with the person receiving care. All of this will contribute to the reduction of the nocebo effect and the proportional increase in therapeutic adherence.
