How an incorrect Diagnosis of arthritis can become a self-fulfilling prophecy
What is a Nocebo?
We have all heard how potent placebos can be. Where the words of a doctor or therapist, reduces pain, as they create an overly-positive picture of a condition, or disease. Even in the absence of drugs or hand-on treatment, these optimistic words significantly reduce pain.
Placebos have been researched for decades now, but there is a new kid on the block. A nocebo, which are just as common and as powerful. Unlike a placebo, which establishes a positive expectation of the future, a nocebo creates a negative expectation.
What Effect Does a Nocebo Have?
The nocebo effect is real, as a “nocebo can have a greater effect than placebo” (Horsfal, 2016). Even if it is difficult to pin down, as the symptoms are non-specific and attributed to other idiosyncratic causes.
“The term “nocebo” derives from the verb nocere (“I shall harm”).” (Planas, 2016). Which is what the research proves a nocebo does. As people who have a gloomy, uncontrollable forecast about an arthritis, hip or knee, will end up feeling more anxious about it. Believing it will be painful, will create a state of constant anticipation, which means the unconscious brain will be on the look out for pain. This belief derived anxiety, has a detrimental effect as its up-regulates the pain response (Adsmundson, 2002). These negative expectations, nocebos heighten pain (Blasini, 2017)
Indirectly, nocebo’s increase pain. This can unnecessarily reduce how much we use an arthritic joint. Having a detrimental effect on the health of a joint. Because joints need blood flow, and muscles surrounding a joint need to be used.
What Causes a Nocebo?
In my opinion he most common cause of a nocebo is in the treatment room of a doctor or therapist. “The nocebo effect is prevalent in interactions between patients and healthcare workers.” Horsfal, 2016
It is probably because people are more inclined to believe an expert. A nocebo is established after the “expert” do the tests and then gives their report of findings. Which is made up of 2 parts: a diagnosis (what it is), a prognosis (How it negatively impacts your future). There are 4 main ways that this report of findings can establish a nocebo: 1- Mis-diagnosis, when a serious condition is falsely implicated (happens all the time) 2- Mis-prognosis, where the future impact is overstated (again very, very common) 3- When they intentionally make it out to be more serious than it is so that they can sell you an expensive solution. Often they make out that there is more structural damage to a joint then there is. 4- Unintentionally, they say a word which suggests to the client, something that the Dr or therapist did not intend. “The verbal and nonverbal communications of physicians contain numerous unintentional negative suggestions that may trigger a nocebo response.” (Planas, 2016)
After a client of mine has have just been given a diagnosis and/or prognosis. Which has set up a nocebo-inducing belief, they tell me how they werenoceboery worried about it, until after they were told it is so severe. They nearly always feel a level of helplessness.
Nocebos are dangerous. I agree with this researcher who says hNocebos are unethical: “The nocebo effect is generally considered unethical because they trigger negative outcomes and do not provide any benefit to the patient” (Planas, 2016)
WHAT YOU CAN DO:
After you are given a diagnose, ask questions! Check that you understood them correctly, and that you have not jumped to conclusions. If they give you a doom and gloom prognosis about your knee or hip. Get a 2nd opinion. Unfortunately, surgeons get paid per operation so they may misled you into getting a joint replaced before it is absolutely needed.
Then, find ways to focus on non-painful activities, finding a pro-active therapist if needed. Concentrate on what you can control promotes autonomy, which boosts the neurotransmitter serotonin, and is a fantastic strategy to reduce the nocebo response (Hauser, 2012).
Psychologists call this reappraisal (McGinn, 2017) which in essence is all about reframing one's perspective (McGonigal, 2015), which reduces the risk of illusionary beliefs from creating pain-inducing nocebos. Whenever I treat or advise I focus on what is fixable, wherever I can.
McGinn, 2017, Psyched Up: How the Science of Mental Preparation Can Help You Succeed
McGonigal, 2015, The Upside of Stress: Why Stress Is Good for You, and How to Get Good at It
Horsfall, 2016, The Nocebo Effect.
Hauser, 2012, Placebo and nocebo responses in randomised controlled trials of drugs applying for approval for fibromyalgia syndrome treatment: systematic review and meta-analysis.
Planas, 2016, The nocebo effect of drugs
Blasini, 2017, Nocebo and pain: an overview of the psychoneurobiological mechanisms
Adsmundson, 200Adsmundsond the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models.