Have you heard about the Nocebo effect?
What does the Nocebo response or effect mean? To illustrate this phenomenon, Jo Marchant, in her amazing book Cure: A Journey into the Science of Mind Over Body recounts an incredible history of what occurred in 2012 at Bibi Hajerah High School (a school for females in Afghanistan). (1)
In recent Afghanistan history, hundreds of terrorist attacks were happening in local schools because of how women were being educated and that had been strictly forbidden I to girls being forbidden in the previous political regime. Even after the country approved the right for women to receive education in 2001, a female attending school was still an act of courage (2).
The classes at the Bibi Hajerah High School for females were normally progressing when one of the students complained about a strong smell, felt dizzy and later fainted. Immediately, acting like an infectious virous, all the students were feeling sick, dizzy and fainting. Within hours more than a hundred students and teachers were struggling to breath and had to be admitted to the hospital. And the media showed armed guards outside the hospital and chaos inside (3).
The police investigation suggested that all the students were poisoned by a toxic gas or water supply because the authorities believed that terrorists were trying to prevent females from attending school.
Intriguingly, although all the students and teachers were seen at local hospitals, the symptoms resolved fast and they all recovered. The hundreds of urine, water and blood samples tests came back without any kind of p (4).
Later, investigations done by the WHO (World Health Organization) interviewing teachers and students, concluded that they were not poisoned. They concluded that this entire outbreak had been caused by a "mass psychogenic illness”.
“Mass psychogenic illness typically affects adolescents or children, groups under stress and females disproportionately more than males. Symptoms often follow an environmental trigger or illness in an index case. They can spread rapidly by apparent visual transmission, may be aggravated by a prominent emergency or media response, and frequently resolve after patients are separated from each other and removed from the environment in which the outbreak began.” (6)
Even science recognize the power of a positive belief as they’ve named it the placebo response. Or the positive healing credited to a medication with an inactive substance or fake treatment. And based on what is known about the biology of the placebo response or effect, the students at Bibi Hajerah were not faking it. The fear or belief that they could suffer a terrorist attack slowly created real physical symptoms for the schoolgirls, even causing some to briefly lose consciousness.
Latin word for placebo = I will please
And the placebo response is a truly fascinating field of science since it challenges conventional concepts of how we heal.
But what is a placebo?
Basically, before launching a new drug on the market, the drug is tested in patients. And patients are divided in groups, where some receive a placebo or a fake version of the drug, and the other group of patients receive the actual drug or treatment. So, at the end of the experiment, researchers evaluate the results of the two groups to know how effective the drug was compared to the result of the placebo group.
A placebo is a treatment or substance that patients in randomized controlled trials receive from their doctors. In most cases, the patients do not know that the treatment they are receiving is a placebo. Instead, patients believe that they are receiving powerful and effective drugs from their doctors.It has the same color and packaging as the drug being tested but have substances with no known pharmacological properties.
Generally, a placebo is the equivalent of a pill made of sugar or starch. Or, inactive substances such as sterile water, saline solution injections and syrups. Or, a fake treatment or medical procedure (including surgeries) or anything simulating a regular medical treatment.
Interestingly, scientific studies shown that one third of patients treated with placebos completely heal themselves or have significant health improvements. And the cures or improvements are credited by the patients to the use of the medication received from their doctors, because they do not know that they received treatments or drugs without any active ingredients, or placebos (7).
Even receiving treatments with inert substances, one third of patients receiving placebos completely heal or have significant improvements in their health.
So, then, the question is: if a placebo is made with no active ingredients, how can these inactive substances have positive effects on the health of these patients? Placebos could not cause effects (they are inactive substances). So, what healed or improved the health of these people?
Essentially, the placebo effect is everything else other than the direct biochemical effect of the pill or procedure. So, what heal people taking placebos is the power of positive thoughts, beliefs or emotions in the medicine they are receiving. The power of a placebo effect is considered a psychological phenomenon.
On the other hand, even placebos can also cause negative side effects on patients. Even a treatment using substances or procedures made without any active ingredient such a placebo, can cause a harmful side effect in patients, which is known as the Nocebo effect (8).
Latin word for Nocebo = I shall harm, or I will harm
The Nocebo effect was introduced in medicine in 1961 by Walter P Kennedy, and is a phenomenon not frequently discussed by health professionals. In fact, only some doctors recognize the Nocebo effect as a negative symptom in a placebo treatment. And they admit that this negative effect is induced by the patient's own negative expectations, increasing the likelihood of adverse effects. It can also be caused by unintentional negative suggestions from doctors and nurses, informing a patient that the medication prescribed may cause side-effects (9, 10).
Consequently, a Nocebo response can cause vomiting, dizziness, headaches and theoretically any kind of symptoms that is linked to the drug it’s mimicking. This can lead to life- threatening conditions. Also, regardless of its pharmacological properties (11, 12, 13).
It’s essential to look at what happened with the Bibi Hajerah student’s as a powerful observation of the effect our mind has on our body. The Nocebo response in this situation linked with the ability of thoughts, believes, emotions, and behaviors, creating a negative and dangerous effect on the health and well-being of these students.
To conclude, the placebo response has a dark side, known as the Nocebo effect. Curiously, not a commonly discussed topics in our medical world, which is why all the health care professionals need to start acknowledging its existence and potential. Finally, the ability to directly affect our body, positively or negatively depending our expectations, beliefs, emotions and behaviors need to be emphasized at a higher scale across the globe.
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