The mind has powerful positive--as well as negative--effects on the body.  This fact may be forgotten in the midst of trying to monitor and treat a complex disease such as multiple sclerosis (MS).  Recognizing and managing mind-body processes are critical aspects of achieving optimal health in MS.

Nocebos and “Voodoo Death”
Many people have heard of “placebo responses,” but most are not aware of “nocebo responses.”  Nocebo responses, which are the opposite of placebo responses, occur when people are told that they will have a negative health outcome and then they actually have that outcome. 

For example, a well-known nocebo experiment involved people who were asked to swallow a liquid.  They were told that the liquid would make them vomit.  Approximately 80 percent of the people vomited.  The liquid was simply sugar and water.  This experiment (and many others with nocebos) indicates that the mind may have a powerful negative influence on health.  That is, if we expect that our health will not be good, then the mind may in fact cause unhealthy events to happen.

In the nocebo experiment with sugar water, a small number of people were involved--the researcher, the research subject, and possibly a family member or friend.  In addition, there was a mildly negative health expectation--vomiting.  What would happen if there was an extremely negative health expectation--such as death--and this expectation was expressed by a large number of people, including friends and family members?  This is the situation with a controversial area known as “voodoo death.”  In cultures with sorcery or other voodoo-like practices, witch-doctors or shamans place death spells that may actually cause death in one or two days.

Autopsies on these people have shown that there is no clear cause for death—these people have not been exposed to poisons, trauma, or infections.  Death may be due to some form of extreme fear or hopelessness.  This type of death may be seen in people with life-threatening health conditions, such as serious forms of cancer, who are hopeful, positive, and living well for months or years—then, they may lose their hope and positive outlook and die, sometimes in a very short period of time.  The expectation of the mind, with the reinforcement of friends, family members, and others, may cause very unhealthy situations. 

Placebos and Beyond
As noted, the opposite of nocebos are placebos.  With placebos, there are positive, rather than negative, expectations of health.  In clinical trials of experimental medications, people are typically given either the active medication or a placebo, sometimes referred to as a “sugar pill.”  In many MS clinical trials, there are notable placebo responses.  For example, in trials of the commonly used, FDA-approved MS medications (glatiramer acetate (Copaxone), interferon (Avonex, Betaseron, Rebif)), people who received placebos had a 15-40 percent decline in the number of attacks.  While there are multiple possible factors to explain this observation, it does indicate that placebo responses may exert beneficial effects on the disease process in MS.

As noted, “voodoo death” may be an extremely negative extension of nocebo responses.  In a similar fashion, what would happen if one extended placebo responses to a much larger scale?  That is, what if there were positive health expectations throughout one’s life and these expectations were shared and supported by one’s social network?  An example of this may be optimism—optimistic people have positive expectations for many aspects of life, including health, and share this outlook with others.  In one 30-year study of nearly 1,000 people at the Mayo Clinic, it was found that the death rate was significantly lower in those who were optimistic relative to those who were pessimistic.

Harnessing Placebo Responses, Eliminating Nocebo Responses
There are many unanswered questions with nocebos and placebos.  However, even with the limited information, there may be powerful ways to improve health by harnessing placebo responses and eliminating or minimizing nocebo responses.  This is not simply a matter of “bucking up” and being happy about everything in life.  Realistically, this is a process that must be individualized and must be worked on and monitored regularly.  One needs to be aware of one’s interests and also one’s strengths and weaknesses.  

Nocebo responses may occur regularly in day-to-day life.  People may have negative feelings about various aspects of their lives, including health.  Family members or friends may share negative attitudes or impose them on others.  It is important to identify and decrease these negative influences in oneself and one’s social network.

Likewise, it is important to develop and nurture positive, optimistic, empowered approaches.  Several specific strategies may be helpful:
• Spirituality and Prayer  This approach may be especially well-suited for those who are already spiritual.
• Exercise  This may be best for those who feel relaxed and empowered when they are exercising.
• Unconventional exercise  Some forms of unconventional exercise, such as t’ai chi and yoga, are excellent for people who want to combine exercise and spirituality.
• Relaxation methods  These methods, such as meditation and guided imagery, are appropriate for those who feel relaxed when they are actually relaxing.
• Alternative medical systems  These healing methods, such as traditional Chinese medicine and Ayurveda, may be best for people who use conventional medicine but have some skepticism about it and would like to have a practitioner who takes a completely different, unconventional approach.
• Psychotherapy  Conventional psychotherapy may provide great benefit to those with significant psychological issues.
• Placebos???  Many of my patients know that I am interested in this area—some of them actually request that I put them on some kind of placebo.  Unfortunately, this raises significant ethical issues.