If a survey were carried out at the doors of a hospital to check if patients are aware of the “nocebo effect”, probably, the majority would answer in the negative. But they may not even know that they themselves – consciously or unconsciously – are experiencing it. Its meaning could be compared to the application of Murphy’s law to the field of health and therapy: “If something can go wrong, it will .”
From a conceptual point of view, the nocebo effect is produced by a series of psychological, physiological and neurobiological phenomena associated with real or perceived damage. These arise as a consequence of the negative expectations of the patients and are not related to the effect of the drug. In other words, self-suggesting that a certain drug will generate adverse effects . It is the opposite of placebo , which invokes a positive attitude and heals just by believing in it.
There is evidence of the nocebo effect “both in research and in daily clinical practice”, rheumatologist Miguel Ángel Abad Hernández, from Hospital Virgen del Puerto de Plasencia (Cáceres), recently pointed out in a webinar that addressed this phenomenon and was organized by the Spanish Society of Hospital Pharmacy and the Pfizer laboratories. And it is precisely that a rheumatological disease, fibromyalgia, is considered one of the pathologies most likely to generate it .
Now, the nocebo effect, is it born or is it made? According to the experts and existing studies, rather the former. “It is something innate to the patient” , considers Abad Hernández. “A kind of defensive mechanism”, Fernando Muñoz, head of the Digestive System Clinical Section at Salamanca University Hospital, gave his opinion at another event on the same subject.
There are some pathophysiological bases, as well as a series of criteria that allow us to identify people who are more likely to experience it. Along with genetic factors, there is a greater predisposition in women compared to men , as well as certain personality traits – anxiety, anguish, worries or the presence of mental disorders -, the patient’s own expectation about the drug or a history of adverse effects . “ Trust in the drug or the company that makes it is also essential . The brand generates positive expectations so as not to have a nocebo effect ”, adds the specialist from the Salamanca hospital.
Likewise, it is convenient to pay attention to your own feedback from word of mouth . And is that the nocebo effect on a patient can influence the rest when negative experiences are shared. A situation that occurs in a special way in the common spaces of health centers: waiting rooms, infusion rooms, etc.
But there are also factors attributable to the drug itself . The influence of aspects such as the color of the presentation – blue is more associated with the nocebo effect -, the price – the cheaper, the more likely it is to be produced – and even the route of administration: parenteral (by injection) has been demonstrated. it is the most conducive. Likewise, the new drugs that have appeared in recent years, such as biosimilars, can generate, due to ignorance, distrust in who is going to ingest them. There is a clear and meridian current example regarding vaccines against covid-19 or, specifically, AstraZeneca doses. The noise generated around its adverse effects can induce any patient immunized with injections of this brand to feel discomfort or a sensation of fever that is not such.
For this reason, when a treatment modification occurs, “it is essential to fully inform the reason for the change and transmit peace of mind on the part of the doctor. If the clinician is convinced, the patient accepts the change and faces it without worries ”, as Abad Hernández advises.
In this line, the third pillar in the fight against the nocebo effect are health professionals. In the case of prescribers, “the feelings or expectations presented to patients regarding a treatment must be positive,” says Carlos Crespo, head of the Pontevedra Health Area Pharmacy. From the consultation, trust should be transmitted, especially if there is an unfavorable context around the drug or product, as explained with the vaccines against covid-19, paying special attention to non-verbal communication. In short, once again, “it is about establishing a positive framework in the consultation and in the relationship between doctor and patient,” Muñoz sentence. and
