The nocebo effect

I have become quite infatuated with hypnosis lately, having done an introductory course. This led to renewed interest into the psychology of everyday medical communication and thus I arrived at the topic of the nocebo effect. There is a lot of literature about the subject, but not very many actually delve into the details.

So here is my short description of the theory.

  • Patients in hospitals (and in particular the ER, OR and ICU) are scared and confused, which leads to high suggestibility.
  • Highly suggestible people can take in every word you utter, so you have to be careful what you say.
  • Most of our daily smalltalky utterances influence negatively.
  • Highly relevant communication such as informed consent, speaking with relatives, is particularly prone to such effects. So we should precisely filter what we tell patients, e.g. about medication side effects to spare them the nocebo side effects. In how far this is ethical, is not too clear.

This might all seem pretty obvious, but the consequences are immense.

  • Our soothing remarks like “just a wee sting here”, “some cold” and so forth mainly serve to soothe ourselves, the will hurt the patient literally. So the best thing is to dump them.
  • If you really want to soothe a patient for a painful procedure, use techniques of everyday hypnosis, like focusing attention on something nice, using narratives and engage the mind in doing things actively instead of hoping for passive tolerance.
  • Our empathic questions about nausea and headache in situations where patients could but should not have these symptoms can really provoke them. It is way better to use a positive formulation, such as “Is there anything we can do to make you feel even better?” [Of course, if you need to know about symptoms for your differential diagnosis, then you still have to ask for them, but remember that in a properly taken history, the patient is supposed to volunteer all relevant information and the review of pertinent symptoms asked in quick succession after the opening phase of the interview should basically all be answered in the negative.]
  • Telling patients about side effects of drugs and procedures should be done carefully, perhaps asking the patient if he or she would be open to forgo a detailed listing if that helps them. Also always use the positive numbers instead of the negative ones and be sure to use the proper modality (90% do fine with LP, a few might get headache). [But beware, people who tend to want to make a choice each and everywhere might react differently to this use of modality, so you have to fine-tune your statement, adapting to personality styles.]

Obviously, I am not an expert on this subject, but my talk should help to interest you in the field. Here are some introductory references.