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

By Elizabeth Preston
Jul 9, 2014 7:19 PMNov 20, 2019 5:31 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

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