S E24: Ep 24 – How Your Brain Can Help (or Hinder) Healing – The Placebo & Nocebo Effects

The podcast is all about giving you useful, practical, tactical tips to help support your wellbeing. And I am joined by my co host, Claire Elsby.

Hello, everyone, my name is Claire Elsby. I've trained in positive psychology and I'm a neurodiverse inclusive therapy coach.

And my angle, if you like, because Bob's very much about the physical, mine's very much about mental wellbeing. And the idea is we bring them both together.

Excellent. Thank you, Claire. Today we are going to talk about two topics.

One is the placebo effect, which most people have heard of, and the other is the nocebo effect, which when I started researching for the podcast, it surprised me at how few people actually had heard of it or knew what it was.

It's actually a really important concept and by the end of the podcast, you'll have an understanding of what the nocebo effect is and why it is so important. But also we'll cover the placebo effect because you may not realize how powerful the placebo effect is.

Starting off with the placebo effect, it's where you give somebody a treatment and there is actually no active ingredient or no active part in that treatment. So for example, you give somebody a sugar pill and they think it's a painkiller. If they've got a headache, they take the sugar pill.

In a significant number of those people that take the placebo, their headaches will go away and they will feel better. It's a really interesting phenomenon, really interesting concept and part of the research for the placebo effect.

Looking at latest data, latest research, it turns out that 97% of GPs in the UK have taken advantage of the placebo effect. That floored me as well because I didn't realize that it was that prevalent and that common.

An example of that is where you go to your gp, they examine you, they find out that rather than a cold, you have a viral infection.

What they may do, it's been a long day, they're tired, they really want to get home, they know that giving you an antibiotic for a viral infection is going to make absolutely no difference whatsoever.

But because you're there, you're feeling poorly, you're insisting that the GP does something to help, they may give you that antibiotic, you'll go away feeling that it's going to help. It's going to work, it's going to make you feel better.

It's a known fact that antibiotics do not work on viral infections, but the placebo effect may well make you feel better, even though what you've been given is going to make absolutely no difference. Another example of it is where you've got somebody who has back pain, really acute low back pain.

They've been suffering for four or five weeks and they know that getting an MRI scan is the ultimate to getting a diagnosis and a resolution to their back pain. So they will hound the GP and say, well, what are you going to do for me? What can you do?

I've had painkillers, I've had all of these things and they've made no difference. I think I need an MRI scan now. Most back pain will resolve within five to 10 weeks, regardless of how acute and severe it feels.

A significant number, I don't know, something like 80% of low back pain will resolve on its own over time.

But if you think that it's the worst thing you've ever felt in your life and the only solution is to find out what it's all about, and you need an MRI scan, a GP may recommend, may refer you for an MRI scan. And again, you walk out of the clinic feeling a bit better because you know that something is being done.

That's another example of the placebo effect. How does a placebo effect work? To be honest, they don't really know.

There are these things called functional MRI scans which they can do on the brain and they can see which part of the brain lights up when certain things happen.

One of the things they have found is that by giving somebody something that they've been told will be beneficial, they found that parts of the brain light up that are responsible for reducing pain. So your body produces endorphins, which are our natural painkillers, and it down regulates the pain sensitivity almost.

So there are a lot of benefits to the placebo effect. But also there is a downside.

There's a study just to compound how powerful the placebo effect is, I'll put a link to a YouTube video in the show Notes where this happened in America. It happened quite a few years ago and I don't think ethically they'd be allowed to do it now.

But what happened was they selected a group of people with severe knee pain, osteoarthritis, and they split them into three groups. Now, two of the groups had a knee operation, one group were told they were going to have a knee operation and they didn't have anything at all.

What they did, all three groups were taken into the operating theatre, obviously one at a time.

And up until getting into the operating theater, the surgeons did know who was going to be operated on or who was going to have the pretend operation. So they took all three groups into surgery. The two groups that were going to have the surgery had the surgery.

The group that were not going to have the surgery because they wanted to observe how powerful the placebo effect was, they were taken into the operating theater, they were prepped for the operation.

None of the surgical team that were in the operating theatre knew who was going to have an operation and who wasn't until they were set up and there was a screen put up above the waist and there was a TV camera in the corner of the room that showed them what was happening in the operation. Now, for the people that didn't have the operation, they had a film of somebody else's knee operation. The surgical team made all the right noises.

There was a clatter of instruments. They went through the whole theater of doing an operation and they actually made some incisions into the knee as well, but they didn't do anything.

Now, post op, everybody was told they had an operation. And the most interesting thing about it was that the group that didn't have an operation, but they went through the sham procedure got better.

They had no operation. There was no surgical involvement whatsoever, apart from the big theater of them thinking that an operation had taken place.

And they got better as well as the people that had had the operation. Now, that is how powerful the placebo is. They didn't actually tell them that they hadn't had the operation until a couple of years later.

If you watch the video, you can see the response. There's one guy in particular who burst into tears when he had severe knee pain. He could hardly walk pre op, he didn't have an operation.

He just went had the theatre of the operation. They tracked him down two years later and they still hadn't told him he hadn't had the operation.

And when he found out, he burst into tears because he thought it had all worked. He'd gone back to his old life, everything was absolutely fine, and then he found out it hadn't happened.

He was still quite happy because he was actually not in pain and everything got better. But that just goes to show how powerful it is now in terms of ethics.

The problem is that if you give somebody an antibiotic that they don't need, you're actually building up resistance in the environment. Because they've been given an antibiotic they don't need.

If you pretend to do an operation on someone, and this is one of the things they don't talk about in the video, they don't actually tell you what happened to the people that had the pretend operation but didn't get better. The problem with placebo is you don't know if it's going to work or not. There is an element of psychology in there. Claire will talk about that.

Placebo is powerful when it works. If it doesn't work, then what do you do? And that's kind of like the ethical side of things.

The other thing as well is that when you've got a GP who's prescribing medication which he knows does not work, but he's under pressure and he's, you know, and he's had a hard day and everything else, so he's given somebody something which he knows doesn't work, but he's told the patient that it works. Again, the ethics behind that, they're difficult to manage.

One of the ways that they have found to make things a bit more ethical is there's this thing called open label placebos.

So one of the things I found, because they've been researching this for a while now, is that you can tell somebody you're giving them a placebo, which is why it's called open label, you can tell them you are giving them a placebo and it still works.

So they're not quite sure how that happens, because the theory is that the brain thinks it's getting something and it triggers a mechanism, which means that you get the natural equivalent of that.

But if you tell somebody that this is a sugar pill and it's going to work and they take it and it works, and their headache goes, or whatever it is you're treating them for, that just goes to show there's a whole area of the brain which we just do not understand. So that's the placebo effect. And then we move on to the nocebo effect.

Now, this is an area which I was surprised that not many people in the medical world talk about, although there's a few that actually know and understand it. So the nocebo effect is where negative situations happen.

Now, a good example of the nocebo effect is in My case, as an osteopath, I see people generally where they've been, been through the health service, they've been through physios, they've been to a consultant, they've been to a gp.

Sticking with the knee pain theme, knee pain is a good one, where they've had a scan and they've been told, well, you've got no cartilage in the knee. That is why you're in pain.

They call it bone on bone, which immediately sets up an image in somebody's head of if they carry on doing what the activities that they were doing, then actually it's going to make things worse, it's going to wear the bone down even more.

So what they do is they go, right, okay, I need to protect my knee, I'm not going to do anything, I'm going to take the medicine, medication, and that's it.

So that's, that's an example of the nocebo effect, because I've seen people that have had this bone on bone issue where with some treatment and with appropriate exercise, they have actually got better and it's reduced, significantly reduced their knee pain. So I would never tell someone that this is your lot, this is what's going to happen.

You know, your knee's worn out, there's nothing you can do about it. Take the tablets and that's it. I would always go, okay, let's see where we are.

Let's work on seeing how much we can improve where you are, and then we'll go from there.

And I also see it with back pain as well, where people have been to see the GP and they've been told they have something terribly sounding called the degenerative disc disease. Now, that's immediate. Sets up an image that my spine is crumbling, therefore I cannot do anything.

Therefore I'm either not going to try or I'm just going to have to learn to live with the pain again. I see people like that. One of the podcasts I did a little while ago, one of the earlier ones, was about something called kinesiophobia.

It's fear of movement through pain. One of the problems with nocebo is that it can be exactly that.

So you tell somebody that the knee is bone on bone, it's wearing out and there's nothing they can do, then they immediately stop moving the knee. You tell somebody they've got degenerative disc disease again.

They have this vision of a crumbling spine and they go, right, I can't do anything because my spine's crumbling. If I do Anything, it's going to wear it out even more.

So those are kind of examples of the nocebo effect and the things that I see and things that I work with. So this may be an appropriate time to go over to Claire to talk about the placebo and nocebo from a mental health perspective.

So I've talked about the kind of, like, the physical aspects of it. Claire's going to talk about the mental health side of things.

Okay. When Bob mentioned this to me, I thought, oh, goodness, that's a. That's a good topic.

So placebo, in my world, the topic I'm bringing to the podcast is actually quite controversial. And I did check it out with Bob and said, can we really talk about this? He goes, yes, we can do controversy.

We can do controversy.

Absolutely fine. So this is about antidepressants, or SSRIs, which are selective serotonin reuptake inhibitors.

I knew that.

Well, you would know that.

I did know that.

You would know that.

So this is coming from a very eminent psychiatrist, Professor Joanna Moncrieff, who's professor of critical and Social Psychiatry at University College in London, and she's also a consultant psychiatrist for the nhs. And she's written a book on this subject and will put a link to the book, hopefully in the show notes. Yep.

And it's called Chemically Imbalanced the Making and Unmaking of the Serotonin Myth. So what does it all mean and what's it got to do with placebo?

So we have been led to believe that depression is caused by a chemical imbalance in our brains, and that antidepressants, or more specifically SSRIs, are the answer to that. And what SSRIs do, in a very generalist way, is increase serotonin, which helps regulate the mood in the brain.

So just to put this into perspective, one in five adults and one in four women are on antidepressants at the moment. Her argument would be that the fundamental theory behind the whole idea of an antidepressant is on shaky ground.

And the reason why placebo comes into this story is that there is a 54 point depression scale.

And when they did the trials, and the trials were very small trials and only lasted over eight weeks, of the people that were in the trial, some were given a placebo. And in the whole of this 54 range depression scale, it only made two points of a difference.

And yet we do know that antidepressants do have side effects and quite unwanted and unhelpful side effects. Now, I need to say that if you are taking antidepressants, don't stop, because it's actually quite dangerous to stop antidepressants quickly.

So you've got to do it under GP supervision very slowly and very carefully.

But it's worth, if you're curious at all, it's worth looking at the work that Professor Joanna Moncrieff is doing in this area and her, I guess her reason behind doing all this work is that she's actually questioning depression itself. And in some cultures there is no such word for depression. It's actually all about the world around you. So it's not you that's the issue.

It's not the chemical imbalance in your brain, it's the fact that things are happening to you beyond your control.

So it's things like relationships, it's things going on at work, it might be financial issues, but it's about really getting to the root of the cause of the issue that's causing our low mood rather than giving a pill. And as Bob said, the GP profession are under pressure.

They only get 10 minute appointments and they have people coming in asking for this because there is a belief that this will fix me. And it's really the GP's easy way as well. Placebo is just to give it, give it to them and they walk out the door.

Yeah, because I think part of it as well is the fact that it is widely accepted. Now, as you were saying, Clare, the evidence for SSRIs and antidepressants generally is pretty weak compared to the effects of placebo.

And there are many, many, many side effects to SSRIs, as we know. So we are not advocating that you stop taking SSRIs.

It would be useful to have a conversation with your GP if you've read the book or if you've done some research and you go to your GP and you talk to them about the fact that you know you're on SSRIs and, and do you need to be, I guess, is the question, would a referral to a clinical psychologist or another therapist be more Beneficial, bearing in mind what the side effects are. So don't stop taking them. One of the topics we covered in a podcast a while ago was managing your appointments with your gp.

So what we covered in that was that if you go into your gp, have a list of questions, ask them what the benefits are of any particular medication or whatever it is that you're on, and ask them what the potential side effects would be if you stopped taking that medication.

Under their advisement, under their, you know, making sure that they are tracking what you're doing and also making sure that they are relatively happy with it.

The challenge is going to be that they, even though they should not be influenced by external sources, it's something that has been widely approved, is widely used, widely available, so they may be reluctant to look at alternatives. We are not here to tell you what to do, we are here to give you advice.

So, as I said, talk to your gp, go there armed with some of the evidence, have a look at the book that Clare was talking about and do some research. That is all we can advise.

Yeah.

Because we're not controversial on this podcast at all.

No, no, no, no, no, no, no, no, no.

Sorry. Right, Clare.

No, no, no. I was just gonna move on swiftly to the nocebo effect. Now I'm gonna, I'm gonna admit I'm one of those people that just didn't know what it was.

I had to do a little bit of research before sitting in this chair. And I find it fascinating the fact that the way that someone could communicate something to you would mean your thoughts almost spiral negatively.

So the example that I could probably give myself is if I go for an injection or vaccination and the nurse practitioner says to me, oh, it's just going to be a little needle, I'm fine with that, fine.

But if she said, oh, actually this is a slightly thicker serum, we need a bigger needle, we need a bigger tube, and she comes out with a massive, big, like syringe, I would immediately be thinking very negative thoughts. Another one is for me going to the dentist.

I only have to walk into the reception at the dentist and I immediately have spiral into negative thinking, even though I've never had a bad experience. So that's a bit random.

So for me, it's about how we communicate things to be able to reduce the effect of the negative talk before, say, a health advisor, a health professional would be administering.

So, for example, someone with health anxiety, in my world, if they're a big givener medication, they are going to read everything that's on the inside of a, you know, a pillbox and they are going to really notice all the side effects. And then as soon as they start to tick the drug, immediately they feel, oh, is that a headache? Is that this? Is that that?

And that is where health anxiety can really be detrimental for somebody and where it becomes a problem for someone, then there is an answer to that. And I would probably be recommending something like cbt.

Some CBT therapy would actually help somebody with health anxiety so that they can actually begin to normalize those thoughts.

Yeah. And just just to add to that as well, another example of the nocebo effect is statins.

The benefits of statins have been recognized and there is some controversy around how they work because they lower cholesterol levels.

And I'm not going to get into the technicalities of how statins work, but one of the things that was widely publicized with statins is that they can cause muscle and joint pain as one of the side effects.

Now, there has been research on this and again, I can put a link in the show notes to the study that I'm talking about where the actual level of side effects from taking statins is around 5% of the population that takes them now because it's got such a bad reputation when they put it in a placebo controlled study where some people were given statins and some people weren't, the number of people experiencing side effects, the muscle and joint side effects was 26%. So the real level is 5%.

But 26% of people that were given either the placebo or statins experience muscle and joint pain when they drill down further into that study, of the 21% of people that had muscle and joint pain, 90% of them were on placebo. So that's how powerful the nocebo effect is.

So even though they were taking a placebo because they'd been told that muscle and joint pain was a side effect of it, even though that in theory should have only affected 5% of the population, 21% of that study were on the placebo and they experienced exactly the same muscle and joint pain. So I just thought I'd throw that one in.

Ye perfect example.

We could put a link in the show notes to that study. But that just goes to show the power of the mind.

This thing that sits between our ears can make us feel better or worse, depending on positive negative outlook on life.

There's different aspects that can make the placebo and nosebin more powerful, but actually this thing between our ears is a very powerful organ anything to add to that? Claire?

No, I just agree with that. Yeah, absolutely. And we still don't understand it all.

We're so far away from understanding it all, it's untrue. But yes. So that is the placebo and nocebo effect. Brought to to you by Bob Allen and Claire Elsby of the Pain Free Living Podcast.

If you enjoyed the podcast, if you learned something, you can put comments in the show notes, give us a five star review. I think we deserve it.

Well, seriously though, if you found this useful, tell your friends, pass it on to people that you think would benefit from doing so, and that's it for now. We'll see you on the next one.