Tina Ryman, MS
Senior Medical Writer
Most people are familiar with the placebo effect—the therapeutic benefit
derived from a patient’s belief in the efficacy of a medically inert substance
or sham procedure. This same power of suggestion can work in a negative way,
whereby patients experience side effects. This is the known as the “nocebo
effect.”
Physicians are legally and ethically bound to explain a
recommended medicine’s benefits and risks as well as disclose the possible side
effects that might occur. However, in the very process of describing side
effects, physicians are potentially building negative expectations in their
patients, which, in turn, can induce a nocebo response.
In Latin, “placebo” means “I will
please,” whereas “nocebo” means “I will harm.”
Why should we as health educators be concerned about the nocebo effect?
Because the damage it can cause is very real, including the following:
- Nonadherence to or discontinuation of treatment
- Frequent changes in medications resulting in
suboptimal care
- More frequent physician and emergency room
visits
- Increased cost of medical care
- Psychological distress
- Increased dropout rate of clinical trials
Nocebo
responses can be nonspecific or specific
Common nonspecific symptoms include trouble
concentrating, headache, drowsiness, nausea, dizziness, insomnia, and vague
malaise. These cannot be necessarily attributed to the pharmacologic action of
the drug involved or the dosage. Moreover, these symptoms may be present before
the patient starts taking the drug. In contrast, specific symptoms are directly
related to the pharmacologic action of a drug and/or its disclosed adverse
effects.
Examples of specific symptoms
Although nonspecific symptoms are the most common
manifestations of a nocebo response, specific symptoms have been well
documented in clinical studies.
One dramatic example is found in a study of the incidence of erectile
dysfunction (ED) among men treated with beta blockers (no placebo was used). Among
the patient subgroups, the researchers found
- The group who were not told the name of the
medicine nor informed of the ED side effect had the lowest incidence of ED
(3.1%)
- The group who were told the name of the medicine
but not informed about the ED side effect had a 15.6% incidence of ED
- The group who were told the name of the medicine
and informed of the ED side effect had the highest incidence of ED (31.2%)
Another dramatic example is provided by a study of 2 placebo groups who
received no medication at all. One group received placebo acupuncture therapy and
the other group received a placebo pill for the antidepressant amitriptyline.
Each group reported the specific side effects associated with their respective
placebo treatment. Although the acupuncture group reported pain during
treatment, increased pain after the so-called "needles" were removed,
and local redness or swelling, the pill group reported drowsiness, dry mouth,
restlessness, dizziness, and headache.
In a study of aspirin and another blood thinner in patients with heart disease
conducted at 3 different medical centers, patients at 2 sites were warned about
possible gastrointestinal problems and patients at the third site were not
warned. The researchers found that the patients who were warned about gastrointestinal
problems were nearly 3 times as likely to report those side effects as the
patients who were not warned. In addition, although the researchers found a
similar amount of actual stomach damage in the 3 patient groups, they noted
that the patients who were informed of the side effect were the most likely to report
pain.
What factors can promote a
nocebo response?
Contributing factors for a nocebo response include
- Psychological
state of the patient: Anxiety, depression, and hypochondria can increase
susceptibility to a nocebo response. Somatization refers to psychological
distress that is converted into physical symptoms
- Past
negative experiences: Patients who experienced side effects in the past are
more likely to experience side effects again, triggered by sights, sounds, or
other cues associated with the negative past experience. Some patients who have
undergone chemotherapy reportedly became nauseated or vomited upon entering the
room where they had previously received chemotherapy
- Pill
color: Symbolically, blue and green colors suggest sedation, and yellow,
orange, and red colors suggest stimulation. In studies, patients taking blue
placebo pills were more likely to report feeling drowsy than patients taking
pink pills
- Verbal
suggestion: The words physicians use to explain possible side effects can
be enough to create expectations about outcomes. Informed consent forms can
also influence expectations
Strategies for minimizing nocebo responses
The nocebo effect presents an ethical dilemma for physicians: on one hand, full disclosure of
possible side effects is required by established ethics of informed consent—yet,
on the other hand, detailed disclosure may produce harm. Despite this ongoing
dilemma, there are some strategies that physicians can use to help avoid or at least minimize a nocebo
response.
- Reframing an adverse event in a more
positive, reassuring way: This
approach gained validation from a study of women in labor receiving epidural
injections for pain. One group was told, “You are going to feel a bee sting;
this is the worst part of the procedure.” The other group was told, “We are
going to give you a local anesthetic that will numb the area and you will feel
comfortable during the procedure.” The group hearing the latter statement
reported significantly less pain than the women hearing the former statement.
Another study found less reported pain when the physicians replaced the word “pain” with the phrase “cool
sensation.”
-
Evaluating and monitoring the patient’s psychological
state: anxiety,
depression, and hypochondria increase patients' risk for a nocebo response.
These emotional states should put physicians on high alert for tailoring their
message carefully
- Educate the patient about the relationship
between emotions, physical sensations, and stress hormones: This step empowers the patient to make a
conscious effort to keep negative emotions in check before they manifest
physically
- Ask the patient to share his or her earlier
disappointing experiences with a treatment or procedure: If the patient indeed has had a bad
experience, the physician can suggest the patient resist expecting a similar
experience, as such anticipation can be a self-fulfilling prophecy
- Demonstrate behaviors that establish trust
and promote the patient’s participation and cooperation: Patients who trust their physicians and are
actively engaged in the decision-making process are in a position of strength and,
as such, more resistant to a nocebo response
An opportunity for education
Although the nocebo effect poses a dilemma for physicians, it creates an opportunity for health
educators. In all likelihood, this issue is not exactly top of mind among busy,
overworked physicians. So it becomes our task to help raise awareness among physicians
of the strong impact their choice of
words can have on patients. We need to create solutions that facilitate the
implementation of the strategies discussed above and that may, in turn, help
enhance quality of care and patient outcomes.
Artcraft Health has many years of experience in creating educational solutions
targeted to healthcare professionals as well as patients. One of our
specialties is creating counseling materials that support a more open and collaborative
dialogue between the physician and patient. These solutions incorporate
insights, strategies, and prompts that assist the healthcare professional in
discussing important issues, addressing individual patient needs, and
minimizing expectation gaps in treatment. Such education empowers patients and
physicians to focus on the treatment objective and establish an open dialogue. At
Artcraft Health, we believe improving patient-physician communication starts
with the appropriate educational solution at the point of care, with the right
message at the right time.
Further
reading:
Collaca L, Finniss D. Nocebo effects,
patient-clinician communication, and therapeutic outcomes. JAMA. 2012; 307(6):567-568.
Wells R, Kaptchuk TJ. To tell the truth, the
whole truth, may do patients harm: the problem of the nocebo effect on informed
consent. Am J Bioeth. 2012;
12(3)22-29.
