Nov 03, 2021
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Psychiatric Times, Vol 38, Issue 11

November 3, 2021

Steve Adelman, MD

(Source: https://www.psychiatrictimes.com/view/a-role-for-psychiatry-in-understanding-and-overcoming-vaccine-hesitancy)


I hope to inspire you to apply your understanding of the human psyche to the curious matter of people who are contracting a life-threatening infection because they are reluctant to heed the advice of their physicians and the public health community. An exuberance of irrationality, not mental illness, seems to be at play here. Can our training and experience as psychiatrists shed light on a flawed decision-making process that leads some people to throw caution to the wind?

Commonplace self-defeating behaviors may be understood from the perspective of those hypothetical constructs known as immature defense mechanisms.1 However, since the 1990s, the so-called Decade of the Brain,2 such psychodynamic concepts have been receding into our profession’s collective unconscious.3 Instead, I will endeavor to gain an understanding of our “culture of hesitancy”4 by invoking the “nocebo effect,” a pharmacotherapeutic construct that is carefully considered by clinical researchers who perform randomized controlled trials of new medications.4,5 

The nocebo effect is at play when individuals receiving an inert or effective medical treatment harbor the expectation that the therapeutic intervention will harm them. Just as placebos have the potential to cure, nocebos can cause pain.6 These days, many anticipate and imagine that a potentially life-preserving inoculation is likely to be harmful. The psychic pain engendered by this negative expectancy may qualify as an anticipatory nocebo effect, akin to anticipatory anxiety.

Regarding COVID-19 immunizations, Amanzio et al7 link vaccine hesitancy in European populations to the presence of potent nocebo effects, especially when individuals are offered specific vaccines with efficacy that is lower than that of the best-performing vaccines. These authors go on to suggest that a psychoeducational approach that acquaints the public with the countertherapeutic nocebo effect has the potential to overcome vaccine hesitancy. Kristensen et al8 describe how potent nocebo effects interfere with the efficacy of biosimilar agents. They suggest that carefully coordinated multidisciplinary communication plans may help to overcome patients’ negative expectancies. Most psychiatrists have a great deal of experience helping mentally ill patients overcome their reluctance to take psychiatric medications. Sharing our hard-earned wisdom with colleagues in other specialties has the potential to be quite beneficial. 

Bagus et al, in Spain, have written extensively about the relationship between nocebo effects, fear, anxiety, and mass hysteria.9 Their view is that media outlets and governments may inadvertently spread a contagion of fear and anxiety that culminates in a set of pathological beliefs and behaviors akin to mass hysteria. This “infectious” disease of pathological belief systems may spread virally through social media and culminate in a shared anticipatory nocebo effect that may manifest as vaccine hesitancy.

Ironically, this discussion of nocebos, a relevant concept in today’s world of randomized controlled trials, has led us to retreat to the somewhat retro and uncomfortable territory of poorly understood sociological phenomena like mass hysteria. Psychosocial speculation of this sort harks back to expansive and speculative works of Sigmund Freud like Totem and Taboo (1913), Civilization and Its Discontents (1929), and Moses and Monotheism (1939).

Psychiatry, a field once dominated by psychoanalytic theory, has robustly embraced neuroscience, brain chemistry, and pharmacotherapy in the past 4 decades. Countless mentally ill patients have benefited greatly from biological psychiatry’s advances. Although we have transcended our mid–20th century love affair with all concepts Freudian, it may be important for us to tap into old-fashioned techniques, such as careful listening, psychosocial formulation, and precise communication, to help patients and colleagues manage better in this challenging era of pseudo-information and reductionistic thinking.10



1. Vaillant GE. Ego mechanisms of defense and personality psychopathologyJ Abnorm Psychol. 1994;103(1):44-50.

2. Jones EG, Mendell LM. Assessing the decade of the brainScience. 1999;284(5415):739.

3. Hunt HT. A collective unconscious reconsidered: Jung’s archetypal imagination in the light of contemporary psychology and social scienceJ Anal Psychol. 2012;57(1):76-98.

4. Williams S. Public attitudes towards COVID-19 vaccination in children: a qualitative study. medRxiv. Preprint posted online July 31, 2021. 

5. Data-Franco J, Berk M. The nocebo effect: a clinicians guideAust N Z J Psychiatry. 2013;47(7):617-623.

6. Colloca L. Nocebo effects can make you feel painScience. 2017;358(6359):44.

7. Amanzio M, Cipriani GE, Bartoli M. How do nocebo effects in placebo groups of randomized controlled trials provide a possible explicative framework for the COVID-19 pandemic? Expert Rev Clin Pharmacol. 2021;14(4):439-444.

8. Kristensen LE, Alten R, Puig L, et al. Non-pharmacological effects in switching medication: the nocebo effect in switching from originator to biosimilar agent. BioDrugs. 2018;32(5):397-404. 

9. Bagus P, Peña-Ramos JA, Sánchez-Bayón A. COVID-19 and the political economy of mass hysteriaInt J Environ Res Public Health. 2021;18(4):1376.

10. Kallivayalil RA. Psychiatry – from biological reductionism to a bio-psycho-social perspectiveWorld Social Psychiatry. 2020;2(1):3-6.