Posts

The Nocebo Effect: When Our Words and Beliefs Make Us Sick

Most 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 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 if the end result is positive.

However, there is a lesser known effect that I believe is more harmful phenomenon that isn’t being discussed enough. 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 placebo, 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. David Chang tackles this in his series Ugly Delicious on Netflix. You can watch the clip here (Warning: uses the F-word a few times). I’m not saying that people can’t be sensitive to MSG (probably really uncommon), but if you are sensitive to MSG in Chinese food, but not Doritos, then you’re not sensitive to MSG, you’re likely expressing a nocebo.
  • 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 without hearing the side effects. [Source]
  • In 1998, a teacher in a Tennessee school reported a “gas-like” smell inside of a school. The school was evacuated, and the ensuing panic from a suspected gas-leak led to over 100 students/staff going to the emergency room with 38 of them being hospitalized over-night. It turns out that it was a false-alarm and no leaks or chemicals were detected so the illness was attributed to a mass psychogenic illness. [Source]

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.


Our minds exert extraordinary influence on our bodies, but our minds are easily fooled for the better with a placebo, or for the worse with a nocebo.

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 MRI 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 talk about disc herniations and tell people that they can’t play sports anymore or lift heavy things because they have disc herniations.

But the evidence is overwhelming in 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 we have taken the patient with a disc herniation and convinced them that their back is weak from herniation and to avoid exercise, we are predisposing this patient to nocebo to 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 placebo or nocebo 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 that we have strategies that reduce the impact of nocebo because nocebos can decrease your ability to recover from chronic pain and illness.

I’ve seen so many patients come into the office that have become so scared of normal human behavior that they may as well wrap themselves in bubble wrap.

This isn’t a 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 and social security card, but you should be even more protective about what you allow to identify as yourself. 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. Having a belief system that your body is capable of facing challenge and enduring allows people to have a condition or illness and not allow the condition to hold them back.
  • Don’t Trust Health Providers That Scare You Into Treatment: It’s one of my biggest pet peeves in the world when I hear other providers using a patient’s condition to scare and coerce people into procedures. I having patients coming in each week that have doctors telling 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 we use fear and scare tactics to coerce people into taking treatment plans, we not only abusing patient trust for financial gain, you 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.

One Season of Football and the Developing Brain

Young Brains and Football

 

Read Time: [5-6 minutes]

 

2016 continues to be a troublesome year for football as science reveals more information about the effects of repetitive head contact on the brain. It’s pretty well established that concussions can create lasting changes in the structure of the brain, in recent years scientists have sought to study if contact sports can change the brain even without concussion.

Two studies presented this year sought to answer that question, and it looks like football without concussions can still affect a young and developing brain. Here are some links to studies below:

Brain Changes seen in youth football players without concussion

Head impact lead to brain changes in high school football players

Both of these studies had a similar design, but they were performed on different age groups. One was performed on players between the ages of 8-13, the other was performed on high school players. Players were given special helmets to quantify how much head impact they were receiving in practices and in games. The players were also scanned with a special form of MRI called diffusion tensor imaging (DTI) before the season and after the season to see if there were any changes in the structure of the brain after the season.

About DTI

DTI helps to measure structural damage to the brain by helping doctors look at a part of a neuron called an axon. Axons are like power lines of a nerve cell. Whenever a neuron fires, it transmits an electrical signal down these wires so that it can pass the message along to the next neuron in the chain. DTI measures the continuous movement of water through these “wires”.

The resulting image is actually something quite beautiful and remarkable to see. Almost like something you can hang in an art exhibition as you can see below:

 

Image Credit: Google Creative Commons

DTI Image of the axons in the brain. Image Credit: Google Creative Commons

 

One of the things that has been well established is that concussions can damage a lot of the axons in the brain through a process called axonal shearing. It’s basically like a hurricane coming in and knocking down your town’s power lines.

 

Image credit to Artery Studios via Pineterest Arterystudios.com

Image credit to Artery Studios via Pineterest
Arterystudios.com

 

When these axons get damaged, that beautiful DTI image that you saw before hand will start to show some gaps like you see below:

DTI Normal vs Abnormal

Back to Football and Young Brains

So we know that concussions definitely cause axonal injury, but what about all those hits to the head that happen without a concussion? Could they also damage these axons?

According to these 2 recent studies, a year of youth or high school football can make observable changes in the structure of the brain.

The studies also showed that the players who had impacts that were more frequent or more forceful correlated with greater signs of damage.

In high school athletes, the researchers also measured functional changes in the brain and showed that players with greater or more frequent impact showed decreased delta wave activity which is a characteristic sign of brain injury.

So far, not so good.

Imaging Is Not A Death Sentence

So before we draw any conclusions, let’s talk about 2 things.

While we know that these DTI findings are related to concussion and head impact diagnosis, we have no idea if this means anything for the health and quality of life of the patient in the future.

Findings on DTI are NOT predictive of how impaired a patient is, nor does it predict if a patient will have future brain damage or post concussion syndrome. In fact, findings on DTI don’t predict all that much at this point in time.

Obviously we prefer that brains don’t suffer any damage at all, but we do know this:

Most people who suffer head impact and concussions will go on to live normal healthy lives.

Now it’s up to science to figure out how much can someone’s brain take, and how do we take care of these people who are at risk for future brain disease.

Email Dr. Chung