Are we dispensing nocebos to patients in pain?

A placebo is defined as a dummy or sham intervention that has no active (‘specific’) ingredient that can affect the target condition.¹ Why and how it is that a dummy treatment can have a positive effect has been the subject of extensive research.^2,3 It is clear that it is not the sham treatment itself that results in the positive outcomes, but the ways in which it is administered. It is the context in which the intervention is given, the interactions that take place between patient and practitioner, and the meaning of the intervention to the patient that are the ‘non-specific effects’ responsible for the placebo response.^4,5 It is also apparent that these non-specific effects of interventions can result in negative rather than positive outcomes. This phenomenon – a patient getting worse after a health care interaction, even though no specific intervention has been administered – is sometimes called the nocebo effect. There is obviously no nocebo equivalent to a placebo – a sham intervention or ‘sugar pill’ – or is there?

What do we mean by nocebo effects and how are they produced? We believe that this is obvious to us all through our everyday experiences. An interaction with another person can leave us suffering – feeling hurt and upset. Similarly, the unexpected or ‘wrong’ outcome resulting from something we have tried to achieve can leave us feeling sad and lonely. Transfer these everyday phenomena to the health care setting and we have what is called the nocebo effect. If the doctor tells us bad news or is rude to us, the effects can be devastating. But does this response affect disease and illness? There has been some research on the short term effects of negative words or suggestions on symptoms like pain,⁶ and it is clear that inducing negative expectations can block the effects of analgesics.⁷ In addition, there is experimental evidence that health anxiety helps mediate nocebo effects, resulting in pain becoming worse rather than better after a healthcare intervention.⁸ There has been very little work on the long term sequelae of a negative consultation, but we are all familiar with the patient who is fuming about the way they were treated by a doctor years after the incident.

These data suggest that if we are to enhance the patient's response to any analgesic intervention through a placebo component, rather than make it worse via the nocebo response, it is critical to relieve anxiety during consultations with patients in pain, and to avoid an interaction that is perceived as negative by the patient. But how do we do that? Recent research has suggested that a useful communication strategy in health care is the validation of patients’ symptoms, and that invalidation can have negative effects.^9,10 Whereas validation communicates acceptance and understanding of another's thoughts, feelings or experiences, invalidation is the opposite – conveying non-acceptance and non-understanding towards another person.¹¹ Although this distinction seems clear-cut, some care is needed – as it is possible to invalidate someone unintentionally. During the medical consultation for example, attempts to reassure a patient may be well intended but invalidating: telling a patient that there is ‘nothing wrong’, for example, can communicate that the patient's concern is not being taken seriously.¹⁰

We have been investigating validation and invalidation of both doctors and patients in the context of consultations for chronic musculoskeletal pain.^12,13 Interviews with both patients with chronic widespread pain, and doctors whom they have consulted, suggest that invalidation is a common and damaging problem for both parties. Patients told us that their doctors had sometimes seemed to deny the presence of their pain at worst, or not seemed to understand its severity and effects on them at best. A common complaint in our clinics is that ‘the doctor did not understand me’. Whatever the reason for that perception, we believe that it can be interpreted as the patient feeling invalidated after a medical consultation. The doctors sometimes felt invalidated by their patients, who seemed unwilling or unable to accept what they were saying, or to believe that they were trying to act in the best interests of the patient.

It is very easy to invalidate a patient who is in pain. Pain is a subjective experience that he/she (the patient) alone understands. We (the doctors) cannot understand it, and we have been trained to be sceptical and cautious – and just occasionally we do meet people who ‘fake it’. So we ask questions and present body language that is often interpreted by patients as indicating that we do not believe them. This can have devastating effects on the patients – both on their pain and on their feelings. It may also result in their giving up on the medical profession, and thus denying themselves interventions that could be of great help.

It has been said that bad is more powerful than good.¹⁴ Teachers know that for every one reprimand you need to give 5 compliments to pupils to maintain their engagement.¹⁵ So maybe a bad word in a clinical consultation is 5 times more powerful than any one good word. Furthermore, in the clinical setting, body language is as important as spoken language, and behaviours interpreted as negative by patients may be 5 times more damaging than we think. We need to balance our natural scepticism and critical facilities – needed to sort out the wood from the trees – with positivity, empathy, understanding and validation of the patients’ problems if we are to avoid administering a nocebo.