Understanding Breast Implant Illness: The Important Role of Nocebo and Placebo-Like Effects

Patients with self-reported breast implant illness (BII) feel that their breast implants are the source of their illness. Social media has supported the concept that breast implants and breast capsules are the source of this illness without clear scientific support or any understanding of the mechanism of BII. However, what social media sites do not explore, and what plastic surgeons experience, is the significant effect that the mind-body connection and anxiety-related disorders have on self-reported BII patients and their symptoms.

THE NOCEBO EFFECT: NEGATIVE IMPRESSIONS THROUGH SOCIAL MEDIA AND OTHER SOURCES

I believe that the “nocebo effect” plays a major role in self-reported BII. The nocebo effect is defined as the negative symptoms or side effects of a potentially harmless substance or treatment, because a patient thinks, expects, or believes they may occur. In other words, patients exhibiting the nocebo effect may report adverse symptoms of breast implants because they think, expect, or believe that their implants are making them ill. The nocebo effect is mediated through mechanisms similar to those that mediate the physiological responses to anxiety, including stress, and negative emotions, with activation of the hypothalamic-pituitary-adrenal axis.

The nocebo effect plays a role in creating the negative impression of breast implants through negative expectations and perceptions gained largely through social media reports and websites. The nocebo effect can be produced through a variety of mechanisms, such as verbal suggestion, consultation with a medical professional, conversations with friends, or through written sources, websites, social media, and other forms of communication. Through these multiple potential sources, in particular suggestions that may arise from sources without medical or scientific knowledge, patients may develop negative emotions and expectations, especially if they have generalized anxiety. A classic example of the nocebo effect was reported by Khan et al, who showed that in countries where negative information about statins is promoted on social media or websites, there are more reports of statin intolerance and adverse events.¹ If we project this concept to the controversy about breast implants, social media and website postings are likely leading to a nocebo effect. This creates negative impressions or symptoms directed towards breast implants.

A PLACEBO-LIKE EFFECT: POSITIVE IMPRESSIONS OF EXPLANTATION

Plastic surgeons may offer a surgical procedure, such as explantation with capsulectomy, to a patient with self-reported BII; however, there is currently no known cause of BII and some patients do not improve despite undergoing surgery. Although explantation is not a placebo procedure, it may have a placebo-like effect because the patient has a high expectation that explantation will make them feel better. It is believed that a placebo effect results from interactions between patient expectations and learning that causes physiological changes including in the immune system, the hypothalamus-pituitary-adrenal axis and the endogenous opioid system.² Therefore, placebo effects can exert real biological effects in patients who expect and believe that a specific surgical procedure will treat their problem.

The placebo effect is a strong factor in treatment outcomes, including drug trials, medical treatments, and surgery. Patients having placebo treatments and serving as a control group have been found in multiple studies to demonstrate outcomes similar to those of treatment groups.³ Studies have also demonstrated that patients with anxiety or anxiety/depression are highly sensitive to placebo effects.³ In the healthcare setting, these patients tend to worry about their health condition and respond strongly to a definitive treatment or procedure. Patients with measurements of anxiety or anxiety/depression are well known to show significant clinical improvement by the treatment with placebo medications, which have been found to be as effective as pharmacological therapy in multiple studies.⁴ It may be that the placebo-like effect of explantation procedures provides relief of anxiety and subjective physical symptoms of BII in some patients.

Glicksman et al recently reported high levels of anxiety in patients with self-reported BII symptoms which reduced following explantation and at least partial capsulectomy.⁵ Patients self-reporting BII symptoms had higher levels of anxiety than patients requesting implant exchange or mastopexy. Anxiety was reduced in the majority of BII patients regardless of the type of capsulectomy performed. Because anxiety disorders are linked to systemic symptoms in many people regardless of whether or not they have breast implants, a placebo-like effect of explantation may have played a role in both the reduction of anxiety that Glicksman et al reported, as well as a reduction of systemic symptoms in some patients.

Evaluating the surgical placebo effect creates ethical issues and is not possible with procedures involving explantation because it is quite obvious to a patient when their implants have been removed. However, in our practice, we have experience with numerous patients with self-reported BII who have claimed that they “feel better” within hours or days following explantation. Patients have reported early relief from anxiety and other symptoms. Interestingly enough, the majority of these patients have a history of anxiety, and many are on medication for an anxiety or anxiety/depression disorder. Did the explantation improve their symptoms with a direct effect or did a reduction of anxiety and a placebo-like effect lead to the improvement through an indirect, psychological effect? We believe that patients claiming self-reported BII are highly influenced by social media and expect that they will feel better once their implants are removed. Some patients do, while others do not. It is likely that among the patients who feel better, especially those who report improvement within hours or days after the procedure, a placebo-like effect and relief of anxiety play a strong role in that outcome. It is suggested that plastic surgeons discuss with their patients the role that anxiety and a placebo-like effect may play in the outcome of an explantation procedure.

I believe that the mechanism of self-reported BII includes a strong psychological component. The nocebo effect plays a significant role in the pathogenesis of self-reported BII by creating or enhancing negative impressions and symptoms which patients believe are related to their breast implants. This tends to produce or enhance anxiety, which in turn, can create physiological and somatic symptoms. A placebo-like effect likely plays an important role in explantation, reducing anxiety and the associated physiological symptoms. The nocebo and placebo-like effects represent important psychological aspects of this self-reported illness.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.