Nocebo Effect
Original Editor - Melissa Coetsee
Top Contributors - Melissa Coetsee, Kim Jackson and Vidya Acharya
Introduction[edit | edit source]
The nocebo effect, the mirror-phenomenon to the placebo effect, is when the expectation of a negative outcome precipitates the corresponding symptom or leads to its exacerbation.[1]
In contrast to the placebo effect of positive expectation which results in health benefits, the nocebo effect worsens the health status due to negative beliefs and expectations. Originally these terms were used for 'inactive' treatments (eg. sugar pill), but the words we use are an integral part of these effects.[2]
Physiology[edit | edit source]
For a long time, the placebo (and nocebo) effect was largely explained by psychological mechanisms, but research has revealed that biological factors are also involved. Some of the physiological mechanisms at play with the nocebo (and placebo) effect include[3]:
- Influence on opioid receptor activation which could block or facilitate analgesia
- Affects neural pathways that mediate pain experience
- Activation of various cortical and spinal cord mechanisms
Language Matters[edit | edit source]
Healthcare is infiltrated with meaning and words, from the jargon of medical terms to the waiting room, interview, relaying of information and clinical mannerisms - which can all influence outcomes.[3]
Research has shown that effective communication skills are paramount for delivering efficient and quality health care. More recently, research has started to show that in addition to how the medical information is delivered, the words used by health care providers are important factors in how patients cope with illness and their reports of pain intensity and disability. [4]
Impact of Language[5]
Communication[edit | edit source]
Patient-clinician communication[6]
Words[edit | edit source]
Emotive power of words[4]
Ethics[edit | edit source]
Informed Consent[edit | edit source]
One of the basic ethical duties in health care is to obtain informed consent from patients before treatment; however, the disclosure of information regarding potential complications or side effects that this involves may precipitate a nocebo effect.[1]
Evidence of Nocebo Effects[edit | edit source]
- ICU[7]
- Postural Stability[8]
- Low back pan: Routine imaging leads to worse outcomes compared to a clinical report (reassurance of incidental findings). Early MRI's for LBP results in longer length of disability, higher medical cost and worse outcomes regardless of radiculopathy (after controlling for severity and demographics)[2]
- Hyperalgesia: Higher levels of fear of pain significantly increases stress levels and is associated with increased nocebo hyperalgesia[2]
Reframing Words[edit | edit source]
In rehabilitation[9][edit | edit source]
Examples in the literature
- A study found that when patients with low back pain are told that a leg flexion test could lead to pain, reported an increase in pain and performed fewer repetitions, than those who were told the test is painless[10].
- Healthcare advice that emphasises structural/anatomical vulnerability of the spine from radiographic imaging, resulted in patients having greater reported disability.[11]
- Various studies have reported that chronic back pain can in part be iatrogenic due to misconceptions and negative beliefs instilled by practitioners.[11]
| Harmful words | Reframed wording |
|---|---|
In Orthopaedics [2]
| Harmful Words | Reframed Wording |
|---|---|
You have to do X before "..."
|
If you do X, you can "..."
|
| You have the joint of an 80-year old | |
| Your joint is bone on bone | A lot of people without pain also have this |
| That is the worst joint I have ever seen | |
| No wonder you are in pain | This doesn't have to be a life sentence to pain |
Clinical Implications[edit | edit source]
It is important to be aware of the impact that words (when we educate, interview, assess) can have on patient expectations, and subsequently on health outcomes. Clinicians who have short interactions with patients, need to carefully consider what to say and convey in the limited time, and those who have prolonged contact with patients (such as allied health practitioners) should continually focus on positive reframing and challenge negative beliefs.[3]
It is not ethical to use positive words, which are in fact false (eg. telling a patient they will definitely recover fully, when this is not the case). One can however leverage the positive effects of words to make the art and science of medicine work together, by combining evidence based interventions with a positive therapeutic experience.[3]At the same time, the effect of evidence-based interventions are at risk of being minimised when combined with a negative therapeutic experience.
Resources[edit | edit source]
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References[edit | edit source]
- ↑ 1.0 1.1 Cohen S. The nocebo effect of informed consent. Bioethics. 2014 Mar;28(3):147-54.
- ↑ 2.0 2.1 2.2 2.3 Dorow B. Words that Hurt, Words that Heal. [PowerPoint presentation]. Kaiser Permanente Persistent Pain Fellowship.
- ↑ 3.0 3.1 3.2 3.3 Benz LN, Flynn TW. Placebo, nocebo, and expectations: leveraging positive outcomes. journal of orthopaedic & sports physical therapy. 2013 Jul;43(7):439-41.
- ↑ 4.0 4.1 Vranceanu AM, Elbon M, Ring D. The emotive impact of orthopedic words. Journal of Hand Therapy. 2011 Apr 1;24(2):112-7.
- ↑ Stewart M, Loftus S. Sticks and stones: the impact of language in musculoskeletal rehabilitation. journal of orthopaedic & sports physical therapy. 2018 Jul;48(7):519-22.
- ↑ Colloca L, Finniss D. Nocebo effects, patient-clinician communication, and therapeutic outcomes. Jama. 2012 Feb 8;307(6):567-8.
- ↑ Huynh KN, Rouse-Watson S, Chu J, Lane AS, Cyna AM. Unheard and unseen: The hidden impact of nocebo communication in the Intensive Care Unit. Journal of the Intensive Care Society. 2023 Nov 29:17511437231214148.
- ↑ Russell K, Duncan M, Price M, Mosewich A, Ellmers T, Hill M. A comparison of placebo and nocebo effects on objective and subjective postural stability: a double-edged sword?. Frontiers in Human Neuroscience. 2022 Aug 18;16:967722.
- ↑ Hohenschurz-Schmidt D, Thomson OP, Rossettini G, Miciak M, Newell D, Roberts L, Vase L, Draper-Rodi J. Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect. Musculoskeletal Science and Practice. 2022 Oct 21:102677.
- ↑ Pfingsten M, Leibing E, Harter W, Kröner-Herwig B, Hempel D, Kronshage U, Hildebrandt J. Fear-avoidance behavior and anticipation of pain in patients with chronic low back pain: a randomized controlled study. Pain medicine. 2001 Dec 1;2(4):259-66.
- ↑ 11.0 11.1 Lin IB, O'Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ open. 2013;3(4).
