The Nocebo Effect

Prof Dr BM Hegde 17 November 2014

The anticipation of disaster is often worse than the disaster itself

Ellen Langer is probably the longest serving psychologist at Harvard, at 67 years. No one, to date, has done as much research as she has on the connection between the human mind and disease.

Her research has brought to light the vital role that mind plays in causing as well as curing disease. She is the one who gave respectability to the placebo effect—the good that a positive mindset can do for the body. She showed that the fear of disease and negative prognoses, especially in cancer and heart disease, are among the most important factors that interfere with the body’s healing capacity, also termed the ‘Nocebo’ effect.

One case report is very significant. There was a middle-aged man who came for a check-up; his routine chest X-ray showed a coin lesion—a small rounded shadow whose details were not clear.

The doctors told him, in no uncertain terms, that the ‘coin lesion’ was due to cancer and needed further probing. The man got admitted and, to cut a long story short, he was dead in six months due to fast spreading lung cancer. These should not be called cancers. They have a new name—incidentalomas.

One of his relatives was a doctor who happened to look at his miniature chest X-ray taken 30 years earlier when he joined his government job. The coin lesion was there at the same place.

The moral of the story is that if that coin were malignant, he would have died long ago. The minute his mind was given the Nocebo signal, the cancer started growing very fast, to kill him in six months. That shows the power of the mind over the body. Both have now been shown to be two faces of the same coin.

Langer’s recent study tried to quantify the Nocebo effect. “In that study her staff will encourage the women to think anew about their circumstances in an attempt to purge any negative messages they have absorbed during their passage through the medical system.” This is crucial, Langer says, because just as the mind can make things better, it can also make things worse. The Nocebo effect is the flip side of the more positive placebo effect; she says that one of the most pernicious Nocebo effects can occur when a patient is informed by her doctor that she is ill. The diagnosis itself, Langer says, primes the symptoms the patient expects to feel. “You change a word here or there, and you get vastly different results,” Langer says. She told scientists about a yet-to-be-published study she did in 2010, that found breast-cancer survivors who described themselves as ‘in remission’ were less functional and showed poorer general health and more pain than subjects who considered themselves ‘cured’.

Another patient of mine comes to mind. The septuagenarian former governor of Karnataka had his routine check-up with an illustrious Delhi cardiologist, who saw his ECG (electro-cardiogram). He pronounced that the old man had serious heart disease and needed an urgent angiogram and may be either an angioplasty or a bypass after that. Someone told him to see me.

I found that the anomaly was seen even in his ECG report taken 35 years ago.

When I told him that he needs no treatment, as this must have been a condition that he was born with, his doubt remained because his other cardiologist was an illustrious one and could not have been so wrong! I took the two readings and explained the changes in great detail to him, showing him that whatever ‘serious disease’ he was supposed to have had was there 35 years ago also. If he could be active and working for 35 years with the block, he could go on for another 35 years.

His face brightened and he is still alive, kicking and active! Removing his Nocebo effect did the trick.

May I earnestly appeal to our colleagues not to frighten patients with Nocebo thoughts in the first place?

‘You have cancer and only six months to live’; 'if you do not get angioplasty right now you might die on your way home’. Some cancerologists argue that they have to tell the patient the truth.

Where is the truth in their statement? Science does not know what cancer is? How do we so confidently give the patient a death warrant? Even if one has to tell a small lie to avoid a Nocebo situation that might save a life, it might be worth weighing our words, before we speak as doctors.

“The art of medicine consists in amusing the patient while nature cures the disease.” — Voltaire

(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS.)

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