The Expectation Effect

In many cases, a person’s symptoms do slowly decline once the possibility of a physical threat has been eliminated and their brain has updated its predictions – but that can only work if the patient trusts the experts bringing the news. If experts don’t deliver the message in a sensitive manner, patients are likely to discount the psychogenic explanation and may even decide that there is some kind of cover-up by the medical profession. This will not only exacerbate their own suffering but also increase the chance that they will transmit the expectation of illness to other people.

This is why we urgently need greater public awareness of expectation effects more generally. Fortunately, there is now evidence that teaching people about nocebo effects, and their power, can help protect them from future mental pathogens.

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On an individual level, we can all try to be more discerning in the ways we think about potential new health scares. Be aware that personal stories, while compelling, do not provide strong evidence of a real danger and that the symptoms people report may arise from many sources. Check that media reports are based on reliable scientific research and look for comparisons of symptoms in people who have and have not been exposed to the supposed threat. (Like the placebo-controlled drug trials, any good study should ideally include some kind of ‘sham exposure’ that can test whether expectations have played a role.) If there is no difference between those populations, you probably don’t need to worry: the symptoms are largely the product of expectations. Even if there is a difference, try to take note of whether the absolute risk is high or low. For many health scares – like statin intolerance – the purely biological side effects are still very rare. (If you have serious concerns for your health, you should of course consult a doctor.)

As people increasingly come to appreciate the power of expectation to create symptoms, we need to abandon the stigma attached to psychogenic and psychosomatic illnesses. Society has, after all, made important strides in advancing our conversations around mental illnesses such as depression and anxiety. Yet people are – quite inexplicably – much more dismissive of conditions that may arise in the mind but then influence the body. According to one of the specialists I spoke to, this stigma is sadly prevalent among medical professionals, who may communicate their disdain to their patients.

The truth is that we are all susceptible to expectation effects that can bring about real physical discomfort. Discovering that fact should be no more shameful than having a regular infection, a broken bone or clinical depression. Psychogenic and psychosomatic symptoms are a natural result of the brain’s extraordinary prediction machine, and a recognition of their psychological, social and cultural origins [...]

Many of us form inaccurate food memories like these every single day – with serious effects on our waistline. The unhealthy habit of working, watching TV or surfing the internet while eating can act as a distraction that impairs memory formation of the food that we have consumed, reducing our expectation of feeling sated. It’s actually analogous to what we see with amnesiac patients, because you’re not able to encode those new meal memories,’ says Higgs, who has investigated this phenomenon. As a consequence, we not only eat more during the meal itself, but we will also eat more snacks over the next few hours.¹²

He [Dr Raffaele Sestu, a doctor in the small town of Arzana, Italy] has worked with dozens of centenarians in his practice and says that most are treated with reverence, as the head of the family, well into their old age. ‘Someone who knows they have a role, and who believes in him- or herself, lives a better life, and more easily lives longer than a hundred,’ he told me.⁵²

Sadly, this attitude seems to be missing in many industrialised countries across the Americas, Europe and Asia, where fewer and fewer people live in intergenerational households, and older people are more often treated as a burden rather than a valued member of the family.⁵³ This mindset is a disadvantage for children and grandchildren, as well as grandparents: various studies show that regular contact with elders can lead younger people to develop more positive views of ageing. As those children reach adulthood and middle age, those experiences will help them to remember what healthy ageing can look like. People who do not have that regular contact, in contrast, are more easily swayed by the ageist stereotypes in the media.⁵⁴ When you do not regularly see people of a certain demographic, it can be easy to either ridicule or disparage them. It is a sad irony that our medical care has been able to increase life expectancy, and yet – due to other social changes – we have come to view those resilient long-livers as a nuisance rather than people to be cherished and respected.