How do the Placebo Effect and the Nocebo work?

When a medicine is administered, it is not only what it contains, but also the position of patients in relation to the pills, creams or syrups with which they are treated, since the mind is as important as the substances that the drugs contain.

This is demonstrated by a known and a lesser known effect: Placebo and Nocebo. Placebo is a term known to most people.

“The positive body and mental changes produced after taking a drug without active substance are known as the placebo effect”, explains Ulrike Bingel, professor of Clinical Neurosciences at the University Clinic of Essen, Germany.

“It can arise even during an apparent treatment, such as a simulated operation, or after drinking an infusion with a simple saline solution,” adds the expert.

This has to do with the expected effects that, according to Bingel, depend on complex psycho-neurobiological processes. This means that faith in the effectiveness of therapy can activate mechanisms that reinforce success.

This positive expectation means that patients can make use of “a kind of pharmacy that their own body relies on” and whose effectiveness must be taken into account. “Through images you can see that certain areas of the brain are activated, such as the systems that are responsible for relieving pain,” he says.

If the patient assumes that taking a medicine will relieve his pain, the brain generates analgesic substances. “These are the body’s own opioids that can even modify the transmission of pain in the spinal cord,” Bingel observes.

“This makes the pain subside despite the fact that the patient suffering from back pain has not taken any opioid analgesic,” the expert explains.

Something that also helps is when the affected people have already experienced the effectiveness of the remedy before. “In that case it is simpler to reproduce the reaction patterns in one’s own body through one’s own expectation,” says Winfried Rief, professor of Clinical Psychology and Psychotherapy at the University of Marburg in Germany.

“If I know that pain relievers help my headache and I take a placebo thinking it is a pain reliever for a headache, there is likely a positive effect,” he adds.

If you have not had previous experience with this type of medicine, it is more difficult. In the case of chronic diseases, in the course of which patients often lost faith in treatment, the placebo effect also reaches its limits, unless new optimism is aroused.

However, the placebo effect is not only related to drugs that do not have active ingredients. “In almost all successful treatments in medicine today it is a combination of direct biochemical effects and psychic effects,” says Rief.

“Studies in the area of ​​pain management show that in almost all cases a double dose had to be administered when there was no placebo effect,” he explains.

However, the opposite is also possible: sometimes a nocebo effect appears. “There are two types,” says Rief. On the one hand, side effects that “cannot be explained biochemically” can develop when giving a drug. “They arise on their own because of the negative expectation in relation to the treatment,” says Rief.

On the other hand, it may happen that a positive effect is not recorded despite the fact that an effective drug has been administered. “If a patient learned, for example, from the neighbor or on the Internet, that relevant side effects could arise, that increases the likelihood that the patient will actually develop those side effects,” he says.

The causes of this negative effect can also be seen in the brain: “When the person expects to feel pain, the pain centers in the brain are activated,” explains Rief. “From an evolutionary point of view, this was an advantage: if you start on the basis that there is a threat, the body prepares for it in advance.”

Studies show that negative expectations can lead to changes in the central nervous system. “Fear of pain can, for example, block opioids and inhibit a chemical messenger like dopamine,” warns Ulrike Bingel. “This causes the transmission and perception of pain to increase rather than decrease.”

Whether it is the placebo effect or the nocebo effect, in both cases the communication between the doctor and the patient is very important. “The physician can promote positive expectations and confidence in the patient. This plays an important role in the effectiveness of therapy,” says Rief.

“If side effects of the treatment can be expected, they can be dramatized or better said something like: ‘You may have a mild headache in the morning when taking the medicine. That means you are acting in the right place.'” , describes the expert. Phrases like this make the treatment go positively.

For her part, Bingel is also convinced that doctor communication is a central factor. “Doctors can explain to patients that 10 percent of people perceive side effects or tell them that 90 percent of patients tolerate the medication very well,” he exemplifies.

They are the same data, but presented in a different way. “It is not a question of downplaying the information or putting makeup on it,” Bingel clarifies. “But doctors can convey the information in a way that doesn’t scare patients.”