What do wellness and the nocebo have to do with one another? Very little. But an odd paradox arose today, which prompted me to sit down and write a little rant. My hope is that we all begin to think more about what we’re doing and how it impacts the end result, rather than just continuing our current routines.
Recently I had a patient whose case looked like one I’ve seen hundreds (perhaps thousands) of times before. The classic case every practitioner who treats back pain knows so well. Patient reported with low back and buttock pain with no true radicular symptoms following a series of repetitive flexion activities. A common condition, from a common cause. A common solution was found and was successful after reassessment. But there’s more to the story.
As worked with this patient I was aware that she had been to another chiropractor and was dissatisfied, prompting her to seek my care. I didn’t ask much about what was done previously. After I was done treating her, the patient showed me a written report from the previous chiropractor. The written list included a multitude of ‘abnormal’ exam findings from range of motion limitations to pelvic unleveling and torque. It also included imaging findings of disc space narrowing and spinal decay (diagnosed by x-ray), numerous subluxations, areas of trigger points and spasm, abnormal spinal curvatures, and likely others I’m forgetting. While I acknowledge these findings are likely accurate (and commonly reported by many chiropractors), I question 2 things. 1) There importance considering until a week ago the patient was smiling, happy, & healthy. 2) The way they are presented. We are seeing more & more that presenting people the idea that something is wrong can be very disabling. This is called the nocebo effect. If you tell someone something is wrong, it often becomes a self-fulfilling prophecy.
“For each ailment that doctors cure, they introduce ten others in healthy individuals by inoculating them with a pathogenic agent, thousands of times more virulent than any microbe- the idea that they are ill.” – Marcel Proust, The Guermantes Way
Wellness defined: Wellness is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. – World Health Organization
Nocebo defined: a harmless substance that when taken by a patient is associated with harmful effects due to negative expectations or the psychological condition of the patient.
- Keep in mind that ideas and perception are the driving force behind the nocebo effect. Giving someone the idea that they are not well, or may not be well in the future is what creates symptoms, not the sugar pill or saline injection. Thoughts, ideas, and poorly delivered diagnoses or reviews of findings can create disability and illness.
This has been common knowledge for some time, but has not been put into clinical practice. It has been studied and written about in the general media. The nocebo is real. “in double-blind clinical trials of antidepressants, even those participants receiving a sugar pill report side effects like gastrointestinal discomfort if investigators have warned them at the outset that those effects are likely.”from The Nocebo Effect Time Magazine in 2009. Also in the Huffington Post, read about pessimism and the nocebo.
Funny video with Dr. Ben Goldacre. (Warning: contains crude language.)