The Nocebo Effect and Psychogenic Illness (and Death)
A PERSON’S BELIEFS, ANTICIPATIONS AND FEELINGS can affect health, illness and treatment both positively and negatively. They can even work against the proven biological mechanisms of action of drugs, indicating the power of belief and feeling over pure biochemistry. In other words, they can actually prevent a medication or drug from working through its known and established biochemical pathway, and this is something acknowledged in the scientific literature, posing a problem to pharmaceutical research.
This proves that the affair belongs entirely to Allāh (عز وجل), and that even if causes are certain, they can be prevented or overturned by other causes that are not understood. Allāh (عز وجل) has put certain powers and potentials within the body which can induce either healing or sickening, independent of the mechanism of action of medications The fact that this is observed and experience is proof that pure reliance upon Allāh (without taking any other means, such as medication) is in itself a means, rather the greatest of means.[1]
Shaykh al-Islām Ibn Taymiyyah (رحمه الله) said:[2]
Many of the ill, or the majority of the ill are cured without medicinal treatment, especially the bedouins, the inhabitants of the various towns and those living in the various parts of the earth. Allāh cures them by the powers (faculties) made inherent in their bodies that can relieve [the body of] the illness. And likewise [He cures them] on account of what He facilitates for them of a physical movement or a [performed] action, or an answered supplication, or a beneficial ruqyah, or a strength of the heart, or good reliance [upon Allāh] and other than that from the many ways besides medicinal treatment.
Prophetic Guidance
There occurs in the ḥadīth of Ibn ʿAbbās (رضي الله عنه):[3]
When the Prophet (صلى الله عليه وسلم) used to enter upon the ill when visiting them he would say: “Don’t worry, it is purification, if Allāh wills.” So he entered upon a bedouin that he was visiting and said to him: “Don’t worry, it is purification, if Allāh wills.” But the bedouin replied: “You said purification? Rather, it is a fever that boils within a man and sends him to the graves.” So the Prophet (صلى الله عليه وسلم) said: (فَنَعَمْ إِذًا) “Then yes, it is (as you think it to be).”
Ibn Rajab (رحمه الله) commented on this ḥadīth:[4]
Meaning, he did not accept the [element of] purification in the fever, and he spoke of his fever in the way he informed about it from his own self, so that which he chose for himself is what happened to him.
Ibn Ḥajar (رحمه الله) said:[5].
Its meaning is: If you refuse [that it is but purification], then, yes, meaning, it will be as you think it to be.
Ibn Ḥajar then quotes from other authorities who bring additional reports indicating that the man died the next morning.
Shaykh Ibn Al-ʿUthaymīn (رحمه الله) said:[6]
Emotions have a great effect on weakening a person. So sometimes the healthy person might think he is ill and thus becomes ill. And sometimes a person ignores illness while he is ill and he becomes healthy. Thus, the soul being emotionally affected by something has a far-reaching effect.
Shaykh Ibn Al-ʿUthaymīn (رحمه الله) also said:[7]
انظر إلى الجرح يصيب الإنسان إذا تشاغل عنه بأموره نسيه ولم يحس بألمه ، وإن ركز عليه أحس بالألم... وهذه قاعدة خذها في كل شيء ، في كل مرض عضوي أو نفسي : أعرض عنه وتغافل عنه فإنه يزول عنك بإذن الله.
In these recent times, people’s delusions and their (false) imaginations that what afflicts them is due to the evil eye, magic, or jinn have increased. Some have even gone so far as to say that when a person catches a cold, they are afflicted by the evil eye, magic, or jinn.
This is wrong. O Muslim brother, ignore all of this, put your trust in Allah and rely on Him. Do not be tempted by any whispering, until it goes away from you, because when a person thinks about something, he feels it. But if he ignores it and abandons it, he will not be harmed.
Look at the wound that afflicts a person. If he is distracted by his own affairs, he forgets about it and does not feel its pain. But if he focuses on it, he feels the pain... This is a rule that you should follow in everything, in every physical or psychological illness: ignore it and disregard it, for it will go away from you, by Allāh’s permission.
Nocebo Effect and Psychogenic Illness
Around 70% of a group of students who were told that they were going to be subjected to an electrical impulse that is able to cause headaches. Though no electrical current was used at all, their thoughts, imaginations and expectations led them to experiencing headaches.
Nocebo: The psychologic induction of pain[8]
More than two-thirds of an unselected sample of 34 college students reported mild headaches when told that a (nonexistent) electric current was passing through their heads. These reports appeared independent of whether the instructions emphasized the headache-producing effect of the current or whether the emphasis was on a perceptual task, with headache as only a possible side effect. The results are consistent with a view of pain as localized stress. They provide additional grounds for the suspicion that clinical focusing on pain may itself be a cause of pain.
Psychogenic Illnesses[9]
The mind’s unfortunate ability to cause suffering is well established, and this phenomenon lies at the heart of the nocebo effect. One such example, known as “The June Bug,” occurred in a textile factory in the United States in the early 1960s. Many employees began to feel dizzy and had an upset stomach. Some people vomited. Rumors of a mysterious bug that was biting employees began to circulate, and eventually sixty-two people who worked at the factory became ill. So what were these mysterious bugs? According to experts, they were nothing—literally. The CDC investigated this outbreak, but no bugs or any other cause of the illnesses could be identified. It instead appears to have been a case of what has often been labeled “mass hysteria,” though it is now called psychogenic illness.
“It Is As You Think It To Be”
Placebos Prove So Powerful Even Experts Are Surprised; New Studies Explore the Brain's Triumph Over Reality
Many doctors know the story of ''Mr. Wright,'' who was found to have cancer and in 1957 was given only days to live. Hospitalized in Long Beach, Calif., with tumors the size of oranges, he heard that scientists had discovered a horse serum, Krebiozen, that appeared to be effective against cancer. He begged to receive it.
His physician, Dr. Philip West, finally agreed and gave Mr. Wright an injection on a Friday afternoon. The following Monday, the astonished doctor found his patient out of his ''death bed,'' joking with the nurses. The tumors, the doctor wrote later, ''had melted like snowballs on a hot stove.''
Two months later, Mr. Wright read medical reports that the horse serum was a quack remedy. He suffered an immediate relapse. ''Don't believe what you read in the papers,'' the doctor told Mr. Wright. Then he injected him with what he said was ''a new super-refined double strength'' version of the drug. Actually, it was water, but again, the tumor masses melted.
Mr. Wright was ''the picture of health'' for another two months -- until he read a definitive report stating that Krebiozen was worthless. He died two days later.
Doctors who know this story dismiss it as one of those strange tales that medicine cannot explain. The idea that a patient's beliefs can make a fatal disease go away is too bizarre.
But now scientists, as they learn that the placebo effect is even more powerful than anyone had been able to demonstrate, are also beginning to discover the biological mechanisms that cause it to achieve results that border on the miraculous. Using new techniques of brain imagery, they are uncovering a host of biological mechanisms that can turn a thought, belief or desire into an agent of change in cells, tissues and organs. They are learning that much of human perception is based not on information flowing into the brain from the outside world but what the brain, based on previous experience, expects to happen next.
New York Times — 13 October 1998
Expecting to die from cancer
One reported case from the 1970s describes a cancer patient who died after being told he had three months to live, only for it to be discovered at autopsy that the stage of his cancer had been misdiagnosed and could not have been the cause of death[10].
A more recent case documented an individual taking part in a clinical trial for antidepressants. He overdosed on 29 capsules and needed to be admitted to hospital for symptoms including severe hypotension. But the adverse symptoms were rapidly reversed when it was revealed he had been taking the placebo[11].
The nocebo effect may also be responsible for the phenomenon of mass psychogenic illness, where symptoms with no apparent cause rapidly spread through communities.
In the above report, the first example was of a man who had been given a diagnosis of metastatic oesophageal cancer which he had been told, had spread through his entire body. He was given a short time to live, just months and he and his family were expecting him to die, which he did. However, his autopsy did not find a single tumour anywhere except for a two-centimetre nodule in his liver. Hence, the man was killed by the expectation of cancer, and not the cancer itself. It was, as he thought it to be.
The effects of chemotherapy by expectation alone
In 1983, British researchers put 400 cancer patients into three groups during a placebo-controlled chemotherapy trial. Two of the groups received different chemotherapy agents while the third received only saline solution. Of the 130 patients in the placebo group, 40 (31%) developed alopecia (hair loss), 45 (35%) experienced drug-related nausea and 28 (22%) developed drug-related vomiting. However, these are all typical, well-known side-effects of chemotherapy and are not symptoms of cancer. Hence, due to their mere belief that they had received chemotherapy, and knowing of the typical outcomes of this treatment, these adverse effects were induced. In other words, they expected hair loss, vomiting, nausea and tiredness, and it was, as they thought it to be.[12]
Illness expectations predict the development of influenza-like symptoms over the winter season[13]
Objective: This study explores the hypothesis that cognitive expectations of catching influenza-like symptoms increase the chances of developing the symptoms over the winter season.
Design: Self-reported data from 247 healthy volunteers were obtained twice, before and after the winter season. In the first assessment, expectations about developing influenza-like symptoms in the incoming months were charted. This data was matched with a post-winter assessment of the actual development of the symptoms.
Results: The odds of developing symptoms were highly associated with the expectations declared months before (OR = 1.776), and the association remained stable (OR = 1.453) even when accounting for previous influenza-like illnesses and the perception of general health. In contrast with previous findings, perceived stress was not associated with symptom development.
Conclusions: These results support the hypothesis of a self-fulfilling prophecy mechanism related to influenza-like symptoms.
Imagine being bombarded day and night with the message regarding the ordinary seasonal flu: “You will catch it, you will fall ill, you will be hospitalized, you will die. Be scared, very scared.” For those who believe these things, the induced fear will then bring compliance to pretty much any instructions that follow. This shows the tremendous power in these affairs and sadly, great potential for this tendency—of expectation, anticipation and self-fulfilment of beliefs and outcomes—to be abused.
You can't catch what you don't fear
After the U.S. Navy’s inconclusive human experiments at the height of the Spanish influenza pandemic, news outlets around the country were quick to jump on these failed attempts to transmit the disease. Several newspapers recounted the elaborate studies and then remarked on how baffling the negative results were. The journalists also offered the confused scientists a word of advice on how to combat the disease. Essentially, these recommended that if people eliminated their fear of the disease, there would not be a single case of Spanish influenza in the entire country—for people could not catch something they did not fear.[14]
Constant fear of infection is one of the surest methods of courting the risk of an attack
Dr. Henry D. Littlejohn[15], of Edinburg, Medical Officer to the Scottish Board of Health from 1862 for 46 years, wrote:[16]
For twenty-five years I have been engaged in active sanitary work, and have had, with very limited staff, to cope with serious outbreaks of Cholera, Small-pox, Fever, Scarlatina, Measles, and Hooping-cough, and although I have during that period brought up a large family, I have never communicated any of these diseases to my children or dependents, nor am I aware that any of the numerous sanitary inspectors who have acted under me have ever contracted or communicated these diseases while in the public service.
To live in constant fear of infection is one of the surest methods of courting the risk of an attack.[17] It is a popular, and I believe a true, saying with regard to Cholera, that the fear of it kills more than the scourge itself.
This holds equally good for other forms of infection; and the Sanitary Inspector; to be an efficient public servant must be assured of this cardinal fact, that infectious germs of all kinds have no power of successfully attacking the healthy individual.
Research Papers on the Nocebo Effect
The nocebo effect (just like the placebo effect) is a problem in pharmaceutical research because it interferes with the biochemical mechanisms of drugs. It can also serve as a useful scapegoat for explaining away adverse effects of drugs, as they can be blamed on negative expectations instead of the drug itself, in some cases. So it’s a complicated issue. Nevertheless, the power of negative thoughts and expectation of adverse outcomes, driven by beliefs plays a role in health and disease.
In the research papers below, the nocebo effect is discussed in the context of beliefs and perceptions about treatments and interventions.
Wartolowska K. The nocebo effect as a source of bias in the assessment of treatment effects. F1000Res. 2019 Jan 3;8:5.[18]
The term nocebo effect refers to the harmful outcomes that result from people's negative beliefs, anticipations, or experiences related to the treatment rather than the pharmacological properties of the treatment.
These outcomes may include a worsening of symptoms, a lack of expected improvement, or adverse events, and they may occur after the active treatment and the placebo that is supposed to imitate it.
The nocebo effect is always unwanted and may distort estimates of treatment effectiveness and safety; moreover, it may cause discontinuation of therapy or withdrawal from a trial.
The nocebo effect may be unintentionally evoked by the explanations given by healthcare professionals during a clinical consultation or consent procedures, or by information from other patients, the media, or the Internet.
Wojtukiewicz MZ, Politynska B, Skalij P, Tokajuk P, Wojtukiewicz AM, Honn KV. It is not just the drugs that matter: the nocebo effect. Cancer Metastasis Rev. 2019 Jun;38(1-2):315-326.[19]
The role of psychological mechanisms in the treatment process cannot be underestimated, the well-known placebo effect unquestionably being a factor in treatment. However, there is also a dark side to the impact of mental processes on health/illness as exemplified by the nocebo effect.
This phenomenon includes the emergence or exacerbation of negative symptoms associated with the therapy, but arising as a result of the patient's expectations, rather than being an actual complication of treatment. The exact biological mechanisms of this process are not known, but cholecystokinergic and dopaminergic systems, changes in the HPA axis, and the endogenous secretion of opioids are thought to be involved.
The nocebo effect can affect a significant proportion of people undergoing treatment, including cancer patients, leading in some cases to the cessation of potentially effective therapy, because of adverse effects that are not actually part of the biological effect of treatment.
In extreme cases, as a result of suggestions and expectations, a paradoxical effect, biologically opposite to the mechanism of the action of the drug, may occur.
In addition, the nocebo effect may significantly interfere with the results of clinical trials, being the cause of a significant proportion of complications reported. Knowledge of the phenomenon is thus necessary in order to facilitate its minimalization and thus improve the quality of life of patients and the effectiveness of treatment.
Horsfall L. The Nocebo Effect. SAAD Dig. 2016 Jan;32:55-7.[20]
A growing body of evidence is emerging for a phenomenon known as the nocebo effect. This is when a person is conditioned to expect a negative response, or to anticipate negative effects from an experience.
These findings highlight the importantance of effective communication with patients and the influence that good anxiety and pain management control can have in improving treatment outcomes. The placebo effect has been widely researched, but new studies have shown that nocebo can have a greater effect than placebo The nocebo effect is prevalent in interactions between patients and healthcare workers.
Research has demonstrated that if a patient deems a healthcare professional not to understand or believe them, this can cause distress, and the physiological effect can reduce the prognosis of treatment.
It has also been demonstrated that patients who are anxious or expect pain during a procedure, feel more pain because of this negative expectation.
Chamsi-Pasha M, Albar MA, Chamsi-Pasha H. Minimizing nocebo effect: Pragmatic approach. Avicenna J Med. 2017 Oct-Dec;7(4):139-143.[21]
The nocebo effect, the inverse of the placebo effect, is a well-established phenomenon, yet under-appreciated. It refers to nonpharmacological, harmful, or undesirable effects occurring after active or inactive therapy.
The frequency of adverse events can dramatically increase by informing patients about the possible side effects of the treatment, and by negative expectations on the part of the patient.
Patients who were told that they might experience sexual side effects after treatment with β-blocker drugs reported these symptoms between three and four times more often than patients in a control group who were not informed about these symptoms.
Nocebo effect has been reported in several neurological diseases such as migraine, epilepsy, multiple sclerosis, Parkinson's disease and neuropathic pain, and in patients with depression. The investigation of the biological and theoretical underpinning of the nocebo phenomenon is at an early stage, and more research is required. Physicians need to be aware of the influence of nocebo phenomenon and be able to recognize it and minimize its effects.
In these and many other papers, it is established that negative beliefs, expectations, anticipations, and prior suggestion and conditioning which induce these affairs, can have biological effects throught the heart-mind-body connection. Though this issue is discussed in a narrow context in the above papers, as it relates to pharmaceutical drug development, it is general in scope and indicates the reality of human nature.
This knowledge has in fact been weaponised and used by those whom we can very aptly refer to as “magicians” who engage in a type of siḥr (subtle techniques, hidden ways and means) to affect the hearts and minds of people in a surreptitious way. They give their art and craft benign names such as “behavioural psychology”, “neuro-linguistic programming” and what is similar. Though these ways could be used for good (positivity, hope), they are used to manipulate thoughts, feelings and behaviours on purpose to fulfil agendas and attain objectives. The Prophetic guidance came to place barriers in front of such affairs and put an end to them, out of which superstition and belief in omens arise. To gain more insight into this, see: Lecture on Belief in Omens from Kitāb Al-Tawḥīd, which will allow you to tie all these affairs together, and to appreciate the nature of this tremendous guidance and its perfection. Note: The people of disbelief openly display these realities to us, rub it in our faces and mock us, and literally tell us exactly what they are doing. See image, “Nothing spreads like fear”, a specifically chosen subtitle to a propaganda movie used to prepare people's hearts and minds to readily accept vaccine pump-and-dump schemes and other socioeconomic agendas without much resistance.
There is an anecdote which has some truth in it. One version reads: A traveller was wandering in the desert when he met Fear and Plague. They said they were on their way to a large city where they were going to kill 10,000 people. The traveler asked Plague if he was going to do all the work. Plague smiled and said, “I’ll only take care of a few hundred. I’ll let my friend Fear do the rest.” In another version: The plague meets up with a large family travelling by caravan to Baghdad. ‘Why are you travelling to Baghdad?’ asked the family elder. ‘To take five thousand lives,’ said the disease. On the way back, they met again. ‘You deceived me,’ said the family elder. ‘You actually took 50,000 lives.’ ‘No,’ insisted the disease. ‘I took 5,000. Fear killed the rest.’
Closing Note
The bedouin whose response to the Prophet (صلى الله عليه وسلم), when he informed him that the fever is a blessing of purification, and that he should not worry, giving him hope, optimism and good thoughts about Allāh, he responded with his belief that fever rages in men and sends them to their graves. As a result, a self-fulfilling prophecy mechanism took him to his grave.
Please reflect on these realities, and try to make the connection between them and between the subject of omens (and likewise, contagion), and see how these tendencies (involving false beliefs, fears, anxieties, expectations, anticipations)— all in the realm of the heart and mind—can be detrimental to a person, to his health and well-being. And if not, then so be it, “it will be as you think it to be”.
By the way, there is a new deadly virus emerging from the bowels of Asia this winter, it has undergone six mutations through Darwinian evolution, making it highly transmissible. You are going to get the flu if you speak to anyone for more than 30 seconds or give them a handshake. Its fast acting, you can be hospitalised within hours, and die within days. Be scared, act like you've got it, and keep your distance from last person, because if they come within six feet of you, you'll be six-feet under in no time.
Are you going to believe these types of narratives and fulfil them through fear and anticipation? Are you going to induce a fever in yourself this winter, and fulfil your own prophecy (or the one broadcast to you), just like the bedouin chose for himself, as occurs in the ḥadīth? Or will you let the Prophetic sciences be your guide and the source of your healing and cure through good opinion of Allāh, placing pure reliance in Him, placing hope in Him alone, having certainty in His decree, and anticipating and expecting your own good health and well-being?
In short: The Prophetic Sciences are definitive and authorititive, and pertain to the loftiest objectives and true beneficial interests, whereas the materialist sciences are speculative and greatly prone to material interests.
Choose wisely.
Footnotes
1. However, this does not apply to all situations, and all conditions and illnesses. For example, if you are in an accident and you break a leg or bleed profusely, you have to take the means to save your life, just as in order to have children you have to get married and have intercourse, they will not come on their own. So everything has a cause or a set of causes, and in many affairs, pure reliance upon Allāh (absent other things) is an effective cause in itself.2. Majmūʿ al-Fatāwā (21/563-366).
3. Related by al-Bukhārī (no. 5656).
4. Majmūʿ Rasāʾʾil Ibn Rajab al-Ḥanbalī (2/376).
5. Fath al-Bārī (taḥqīq, al-Arnāʾūṭ, Dār al-Risālah al-ʿĀlamaiyyah) 17/388.
6. Al-Qawl al-Mufīd (Dār al-ʿĀṣimah: Riyāḍ, 1415H) 1/169.
7. Nūr ʿalā al-Ḍarb (366a).
8. Schweiger A, Parducci A. The Pavlovian journal of biological science 16:140–143, (1981).
9. Bernstein, M. H. The Nocebo Effect (2024).
10. Meador C K. Hex death: voodoo magic or persuasion? South Med J 1992;85;244–247.
11. Reeves RR, Ladner ME, Hart RH, Burke RS. Nocebo effects with antidepressant clinical drug trial placebos. Gen Hosp Psychiatry 2007;29:275–277.
12. Fielding JW, Fagg SW, et. al. An interim report of a prospective, randomized, controlled study of adjuvant chemotherapy in operable gastric cancer: British Stomach Cancer Group. World J Surg. 1983 May;7(3):390-9 via Can You Catch a Cold by Daniel Roytas (2024)
13. Pagnini F, Cavalera C. Complement Ther Med. 2020 May;50:102396.
14. An Official Test. Glendale Evening News. pp. 1-4 (1919), by way of Can You Catch a Cold, by Daniel Roytas (2024).
15. Sir Henry Duncan Littlejohn MD LLD FRCSE was a Scottish surgeon, forensic scientist and public health official during the late 19th century and early 20th century. He served for 46 years as Edinburgh's first Medical Officer of Health, during which time he brought about significant improvements in the living conditions and the health of the city's inhabitants.
16. Henry D. Littlejohn, MD, “Report by Dr. Littlejohn,” The Poor Law Magazine and Parochial Journal, vol. VIII, 1880, Edinburgh, pp. 309-311.
17. This has been alluded to by Muslim scholars such as al-Qurtubī and Ibn al-Qayyim, which is that fear itself can induce either the same illness or some other illness.
18. https://pubmed.ncbi.nlm.nih.gov/31354941/
19. https://pubmed.ncbi.nlm.nih.gov/31203560/
20. https://pubmed.ncbi.nlm.nih.gov/27145562/
21. https://pubmed.ncbi.nlm.nih.gov/29119079/