Placebo Effect

The placebo effect is the beneficial and therapeutic action of an inert substance or treatment not attributed to the properties of the substance or treatment itself, but to the patient’s positive expectations. Faith in the physician as well as the physician’s confidence and enthusiasm play a key role. The substance or treatment may have no actual merit or healing capabilities. The placebo effect has everything to do with the way the physician frames the situation, the power of suggestion, and the patient’s perception that the treatment will be successful. Expectations shape outcomes and if one thinks something will work, it likely will, a testament to the powerful mind-body connection.

“A doctor who fails to have a placebo effect on his patients should be a pathologist.”   

J.N Blau

Nocebo Effect

Nocebo is the opposite of placebo. Equally powerful to the placebo effect, the nocebo effect occurs when a patient is the recipient of an inert substance or treatment and encounters worsening symptoms or the occurrence of new symptoms that were not previously experienced. This happens by virtue of negative expectations regarding the effectiveness of the substance or treatment provoked by the pessimism of the physician about its benefits and/or serious concern about side effects. At times, the simple act of formally labeling a condition can stir the nocebo effect into motion. Once a set of symptoms is given a formal title, pain and an exacerbation of symptoms may occur, possibly triggering the onset of a chronic condition.

Placebo vs. Nocebo

The bedside manner, body language (eye contact, posture, open body versus crossed arms, smile, etc.), “energy” of the physician, choice of words (optimism and hope versus pessimism and panic), and how the physician frames the situation, can make the difference between generating a placebo effect vs. a nocebo effect. If the patient is made to feel that they are in dire straits by virtue of the diagnosis, they are more likely to have a serious nocebo reaction. However, if the situation is framed positively and the patient is reassured that the infirmity is common and often innocuous, they are unlikely to have a nocebo reaction.

For example, a patient seeks a urology consultation complaining of the following symptoms: a penile lump, pain with erections, and a penile angulation when erect. This is classic Peyronie’s disease, scarring in a region in the body that requires expansion and elasticity for proper function. When the patient is informed that he has Peyronie’s disease, he is labeled with a chronic medical condition and negative emotions associated with the nocebo effect may immediately surface, he may become hyper-focused on his penis and may start having heightened symptoms based upon the hyper-focus. He is certain to go home and Google search Peyronie’s disease and read about worst-case scenarios, further contributing to anxiety and symptom exacerbation. Several secondary psychological events may be provoked: somatization, hypervigilance, attentional bias, and catastrophizing. However, the physician’s actions, demeanor, and framing of the situation can prevent the nocebo effect and all of its ramifications. When the label “disease” is de-emphasized and the patient is informed that this malady is nothing other than scar tissue in a bad place and that it can be readily managed, gloom and doom disappear and are replaced with optimism.

Nurturing the Placebo Effect

A skilled physician is adept at tapping into and drawing forth the placebo effect. It requires an enthusiastic and supporting attitude as well as a reassuring, competent, and confident manner. Positive energy is contagious and is of foremost importance. Style of dress and speech, good posture, and proper phrasing of sentences weigh heavily towards achieving this effect. A self-assured and positive statement, e.g., “You will be better soon,” will induce the placebo effect much more readily than hesitant and hedging assertions, e.g., “I’m not sure this will help.” The more time spent with the recipient of the placebo effect, the better the chances of provoking a positive response. Studies have shown that when a physician prescribes a medication, the more expensive it is, the more effective it will often be. The more expensive medicine is perceived as more valuable, in line with theories of cognitive dissonance.

I am not in any way suggesting that a physician should be deceptive or dishonest regarding patient education and the dissemination of medical information and test results, simply that there is an important role for the art of medicine as well as the science of medicine. It is not always what is said that counts, but how it is said.

Placebo Pain Relief

Placebo pain relief is genuine and has a biochemical basis. The placebo effect elicits the release of endorphins, a portmanteau derived from “endogenous,” meaning from inside the body, and “morphine,” an opioid pain reliever. Endorphins are opioid neurotransmitters/hormones manufactured in the brain that activate the body’s opiate receptors causing a pain-relieving effect. Interestingly, placebo responses can be inhibited or eliminated by the administration of naloxone, an opioid antagonist (often used to treat narcotic overdoses in emergency situations) that blocks endorphins. The placebo effect may also elicit the release of other endogenous “happy” chemicals – dopamine, oxytocin, and serotonin — that help provide the biochemical basis of positive results.

Bottom Line: A skilled physician can maneuver an interaction with a patient in the direction of the placebo effect and away from the nocebo effect to the patient’s advantage, often relieving a variety of symptoms and complaints. With respect to pain, the placebo effect can tap into the “pharmacy within,” causing the release of endogenous opioids synthesized in the brain that provide analgesia by impeding incoming pain signals from the body.