s316 Nocebo effects, an appeal for well-formed communication

"Over time, the soul takes on the color of thoughts." Marcus Aurelius

When medicine and doctors make you sick, something is wrong. Sensory stimuli such as the warning on the package insert, visual representations of clinical pictures, risk warnings for personal protection and well-intentioned deterrents can trigger emotive-cognitive cycles that make people sick. What goes “wrong” is generated by doctors, pharmaceutical companies and advertising.

This unintentionally adverse doctor-patient interaction contradicts the ancient principle that the doctor must above all do no harm. An adverse interaction with patients unavoidably triggers internal disease-causing cycles, which can do harm particularly to the already anxious patient. This phenomenon has become known under the term Nocebo.

These sensory stimuli generate internal processes and effects, which the patient gives a stressful or healing meaning. Thus, the stimuli for the emotive-cognitive cycles, which translate into placebo or nocebo effects, do not necessarily function as just well-meaning suggestions and warnings.

In this process, the interaction of the specific construction of the stimulus (through verbal, visual and other non-verbal factors) with an emotional disposition (an anxious patient) can create a particularly dangerous dynamic in certain situations, which ultimately leads to the nocebo effect, in spite of the fact that this effect was not intended by the well-meaning actors.

More in the German article “Nocebo-Effekte, Plädoyer für eine wohlgeformte Kommunikation” on page 14 in the magazine GZM Systemische Orale Medizin.

Well-formed communication as a solution

Despite the complexity of the cyclical principle of action and the subjective processing of internal and external stimuli, effective interventions are possible.

KiE - Emotive-cognitive cycles with the nocebo effect
Figure 01: Emotive-cognitive cycles with the nocebo effect

It is important to differentiate between, what the patient can do in a self-organized way and what doctors, therapists, pharmaceutical and advertising companies can do. You are asked to avoid stimuli so that the stressful emotive-cognitive cycles are not initiated at all. Patients should be able to regulate these stimuli in order to end stressful inner cycles or to convert them into healing ones. An either-or would miss the mark.

In a first step, however, both patients as well as doctors and therapists need solid knowledge of the cyclical-evolutionary principles. Based on such knowledge, stress and negative dynamics could then be recognized at an early stage. Mindfulness techniques are equally suitable for the detection of internal effects as they can also be used for regulation. With the knowledge of these internal cause and effect principles, intervention can be targeted at risky points, so that immediate relief, a stopping of the negative effect or even its reversal can be brought about. In the second step, patients as well as doctors and therapists could then be provided with effective interventions.


August 2020 – Richard Graf, Elsa Graf

Over time, the soul takes on the color of thoughts. Marcus Aurelius


Graf, Richard: Die neue Entscheidungskultur: mit gemeinsam getragenen Entscheidungen zum Erfolg. Carl Hanser Verlag GmbH Co KG, 2018

Hahn, R (1997). The Nocebo Phenomenon: concept, evidence and implication for public health. In: Preventive Medicine; 26:607-611.

Schmidt, G. B. (2013) Bewusstseinsmedizin: Psychogene Heilung durch Vorstellungskraft. In Suggestionen: Forum der Deutschen Gesellschaft für Hypnose und Hypnotherapie; 6-40.

Schröder, H. & Rothe, M. (Hg.). (2008). Stil, Stilbruch, Tabu, Stilerfahrung nach der Rhetorik. Eine Bilanz. (Semiotik der Kultur – Semiotics of Culture, Band 7). Münster: LIT-Verlag.

Graf, R. & Schröder, H. (2020). Nocebo-Effekte, Ein Plädoyer für eine wohlgeformte Kommunikation. Systemische orale Medizin (GZM), 9(2), 14-19.