Say No to Nocebo: How Doctors Can Keep Patients’ Minds from Making Them Sicker

By Elizabeth Preston | July 9, 2014 10:19 am

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“First, do no harm,” the saying goes, but that might be close to impossible. Just as our expectations can make us feel better, they can also make us feel much worse. This means that how doctors phrase their instructions or introduce new drugs may have a real impact on our health. But some doctors are trying to figure out how they can do less harm by harnessing the surprising power of their words.

“In the classical view that is still taught at medical school and in textbooks, drug actions are purely determined by the drug,” says Ulrike Bingel, a neurologist at the University of Duisburg-Essen in Germany. “But that is not true.” She’s a member of the Placebo Competence Team, the steering committee of a placebo research group funded by the German Research Foundation.

The Latin version of “first, do no harm” (for when you want it to sound extra serious) is primum non nocere. The verb nocere means “to harm” or “to hurt,” and it’s the origin of noxious and obnoxious in English. It’s also the source of “nocebo effect,” the lesser-known counterpart to the placebo effect. Nocebo is “I will harm.” It sounds sinister, but it can happen even when everyone’s intentions are good.

For example, Bingel writes in a JAMA Viewpoint, switching from a brand-name drug to a generic version can make people report more side effects—even when the two drugs are chemically identical. In fact, during some drug trials, side effects happen almost as often to people taking the placebo version of the drug as the real one.

Once the trials have ended and a drug is on the market, its packaging has to list every one of these potential side effects for legal reasons—even if some side effects have no known link to the drug itself, and were likely nocebos. Patients who read about these negative side effects may then be primed to notice these symptoms in their own bodies.

Expectations are key to both placebo and nocebo. In placebo, our expectation of feeling better can lead to real physiological changes in our bodies. In New Zealand in 2007, on the other hand, the makers of a thyroid drug changed the manufacturing of their pills so that they were now a different size and color. Rumors spread in the media and online that the new pills were unsafe and would cause side effects. Suddenly, although the drug hadn’t changed, reports of bad reactions to the drug increased 2,000-fold.

Nocebo can not only increase side effects, but can decrease how effective a treatment is. In one migraine study, falsely labeling the real drug as a placebo made it work less well. If patients have tried a treatment in the past without success, their expectations might prevent the same treatment from working in the future.

Doctors need to be aware that patients’ prior experiences can influence how they do, Bingel says—and that how doctors interact with their patients is critically important. In a study of epidurals for mothers in labor, slight changes in how doctors described the procedure affected how much pain the women felt.

Once doctors realize their power, Bingel says, they can start doing things differently. “Use an authentic and emphatic communication style to interact with your patients,” she says. “Explain why you prescribe a drug and how it works.” Doctors should describe the benefits of a drug before pointing out the side effects it might have, she adds.

Bingel also suggests that doctors ask patients questions to make sure they don’t have misunderstandings or bad expectations before a treatment even starts. Doctors can give patients advice about coping with minor side effects, rather than giving up on a treatment. And they can avoid confusing jargon—so they don’t recreate the famous Seinfeld scene where George panics about a “negative” test result. (More of the Placebo Competence Team’s tips are available online.)

“I think that the biggest current barrier is the lack of awareness,” Bingel says. Health-care professionals often don’t realize that the way they talk to someone, along with the whole context of that patient’s experience, can influence how well a treatment works. Once they start paying attention, they may be able to inflict some harm where they really want to: on the nocebo effect itself.

 

See more on placebo and nocebo here.

Image: by Jasleen Kaur (via Flickr)

Bingel, U. (2014). Avoiding Nocebo Effects to Optimize Treatment Outcome JAMA DOI: 10.1001/jama.2014.8342

  • Christopher Sesi

    To the author,

    Although I am almost certain you don’t believe this, the article sounds as though the patient’s subjective report on the efficacy of the drug somehow dictates the actual objective efficacy of the drug. I think it should be clarified that the patient’s view on a drug’s benefits and harms can be skewed based on different factors. Ultimately, patient opinions matter little when it comes to determining how well a drug works. It may matter in terms of patient care and treatment adherence but, contrary to Ulrike Bingel, a drug’s physiological effect is the only thing that determines how well it works.

    • Hayden Smith

      Uh, no.

      • Christopher Sesi

        Very insightful response. I’m blown away by your ability to engage in meaningful discussion. Thank you, jackass!

        • epreston8

          Hello everyone! Disagreements are welcome here, but I’d appreciate it if everyone could respect Discover’s comment policy by being cordial and not using profanity.

          Christopher, the article linked to in this post is open access–if you’d like, you can read it yourself and follow the citations to see specific evidence.

    • Boris Borcic

      Brave New World, Hello. Patient opinions and emotions and mind, according to mainstream science all have physiological implementations. Who benefits from the view that as concerns any eventual interference between drug action and the physiology of the patient’s subjectivity, the flow of control should be from prescription to patient opinion via drugs rather than from prescription to drugs via patient opinion?

  • FeatheredFiend

    The placebo effect has always fascinated me because it implies that the mind is separate from the brain. If the mind and the brain are the same thing, then the physical effects of a medicine could never be changed or simulated by suggestion. It’s interesting that an incorporeal idea can cause physical change in the body, and it would be interesting if more study was put into what causes the placebo effect.

  • margaretbthomas

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  • Lim Myka

    placebo effect is a mind conditioning…if you think you are ill and some herbal medicines have made you much better.. and you feel that you are likely to be healed then it may help a lot..the mind is more powerful than your body…it governs all the aspect of your well being..being a positive person makes you hurdle hindrances in your life..miracles happen because they believe it does..jesus made miracles and those who believe in him are healed,,,

    • QXylashe1964

      ike
      Jacqueline implied I’m taken by surprise that a mom can earn $8130 in 1 month
      on the computer . see post C­a­s­h­f­i­g­.­C­O­M­

  • http://addictionblog.org/ Ivana@addictionblog

    Actually, in many studies, control groups of individuals taking a
    placebo and taking the medication feel similar effects. But, what if a
    patient finds out that he was taking a sugar-pill? Do you think even
    real meds won’t work after?

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Inkfish

Like the wily and many-armed cephalopod, Inkfish reaches into the far corners of science news and brings you back surprises (and the occasional sea creature). The ink is virtual but the research is real.

About Elizabeth Preston

Elizabeth Preston is a science writer whose articles have appeared in publications including Slate, Nautilus, and National Geographic. She's also Editor of the children's science magazine Muse, where she frequently writes in the voice of a know-it-all bovine. She lives in Massachusetts. Read more and see her other writing here.

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