Nocebo effect: Every word is important

Dr. med. Thomas Heller, Medical Practitioner, Bad Schwalbach, Germany

In my role as a medical psychotherapist I only work with words as a rule, so it goes without saying that I am always mindful of words and what is said. However, my patients regularly relay to me comments and quotes made by my medical colleagues which make me shudder. So much good can be done with words, but unfortunately the opposite is also true. Behind many of these remarks I can of course often recognise the good intentions, but as is true in all aspects of life, good intentions do not always make for good results. But don’t worry, dear colleagues – I am not trying to tell you how to do your jobs or upbraid you in any way. On the contrary, my aim is to encourage you to improve on the healing methods you already use by using simple verbal communication tools. When I think of the effect that negative remarks can have in my practice, it seems clear to me that plenty of positive comments are made there too.

Words cost nothing, which means that you and your patients are equally able to make full use of them. You may now be thinking “Each and every word is important – might he be exaggerating just a little here.” I’d much prefer it if, having heard my comments, you instead think “Wait, maybe he has a point – I’ll give it a try.”

What I would like to recommend to you in any event is the book entitled “Die verlorene Kunst des Heilens” [“The Lost Art of Healing”]. Compulsory reading for anyone in the healing profession, maybe while you are on holiday ☺.

Deutsches Ärzteblatt (the official journal of the German Medical Association) explored nocebo phenomena in its 06/2012 issue, devoting its cover story to the subject. It soon becomes clear that, unlike with the placebo effect, we cannot plan studies to examine the nocebo effect because it is not possible or permissible on ethical grounds to intentionally expose test subjects or patients to negative effects; the reason being that – and this is a key argument against trials exploring nocebo effects –doctors are not permitted to harm their patients. But this is precisely what does happen when doctors, nonmedical practitioners or medical staff unknowingly or unwittingly send out nocebo messages.

With regard to investigations/observations/ studies into the nocebo effect, these are often just observations that are, as it were, a byproduct of placebo studies, or else (random) observations which can only be explained in terms of nocebo effects.

Wikipedia also reflects the fact that we appear to know considerably more about the placebo effect than we do about the nocebo effect. Let’s take a look at the information Wikipedians have compiled about the nocebo effect:

Nocebo effect

The nocebo effect (from Lat. nocere = to harm, nocebo = I shall harm) is – similarly to the placebo effect (Lat. placebo = I shall please) – a seemingly negative impact caused by a medicinal product. It describes the response to either an inert medical preparation or to what is believed to be the sustained negative impact on health or wellbeing of an environmentchanging measure. In contrast to the positive impact seen with the placebo effect, the nocebo effect provokes a negative response.

Considerably more has been written about the placebo effect:

Placebo effect

A placebo (Lat. ‘I shall please’) is, in the narrowest sense of the word, a sham medical treatment intended to deceive the recipient, which does not contain any active drug and as a result cannot cause a pharmacological effect. In the wider meaning of the word, placebo is used to describe other sham interventions, such as sham surgery.

Placebo effects are positive changes to subjective wellbeing and objectively measurable bodily functions, such changes being attributed to the symbolic significance of undergoing a treatment. They can occur with any form of treatment and are not restricted to sham treatments.

Placebos are used in placebocontrolled clinical studies in order to record as precisely as possible the therapeutic efficacy of various procedures identified as the verum treatment, ideally as part of a double blind study. The use of placebos to treat disorders outside this type of study is ethically contentious unless such use is based on informed consent and is part of the shared decisionmaking process between patient and doctor.

Informing a patient about the use of placebos seems somewhat absurd to me: you are now receiving treatment without any pharmacological or medical substrate, but we assume that it will help your condition. Excuse me, but how is that supposed to work? In (double blind) studies this can happen of course.

Luckily, however, the patient also has the right not to be informed about side effects and complications; this is the only way that the doctor as drug can be brought into play.

The (more expansive) statements on the placebo effect apply equally of course to the nocebo effect, because the modes of action are the same, but with a negative connotation.

Unfortunately, for copyright reasons, I have to restrict comment on the following areas to my verbal presentation:

  • mode of action
  • studies/observations/trials
  • nocebo phrases
  • nocebo in everyday practice
  • brain/communication
  • mindfulness.

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