The idea that words have immense power over our health has been central to much of my clinical work and lecturing in the last 30 years. I’m currently recording a podcast series on the importance of the mind-body connection in health with some of the world’s leading researchers, and as part of the research for one interview I came across this article about nocebos:
Can Positive Framing Reduce Nocebo Side Effects? Current Evidence and Recommendation for Future Research by Kirsten Barnes, Kate Faasse, Andrew L. Geers, Suzanne G. Helfer, Louise Sharpe, Luana Colloca, and Ben Colagiuri
The paper tackles the tricky paradox produced by informed consent – this is where clinicians have a duty to inform you of any possible side effects of treatment. However, they are also duty-bound to avoid causing harm to their patients, and giving information about side effects has been shown to produce side effects:
“Numerous studies indicate that negative health information can generate negative expectancies that lead to adverse outcomes – labelled the nocebo effect (Colagiuri and Zachariae, 2010; Colloca and Miller, 2011; Faasse and Petrie, 2013). This creates an ethical paradox: informed consent requires that patients are warned about potential side effects (Wells and Kaptchuk, 2012; Colloca, 2015, 2017), but these warnings themselves may produce poorer health outcomes via the nocebo effect (e.g., Myers et al., 1987; Mondaini et al., 2007; Neukirch and Colagiuri, 2015).”
This is not only a difficult ethical dilemma to resolve, but it also has a huge impact on the health of patients:
“The burden of nocebo effects on the healthcare system is not trivial. Nocebo effects account for between 40 and 100% of drug side effects (Mahr et al., 2017). Nocebo-induced side effects can result in treatment termination, protracted treatment, and psychological distress (Barsky et al., 2002).”
The paper continues, noting that how the information about how possible side effects is delivered is important – this is called ‘framing’. The example used in the paper is a ‘negative frame: 30% will experience headache vs. positive frame: 70% will not experience headache’. Obviously, the information in both warnings is the same but the way it’s delivered will affect how we respond to it (see (Kahneman and Tversky, 1979; Tversky and Kahneman, 1981).
There is a further twist to this, which often goes unnoticed, and that is how in both examples, the word headache is used. Interestingly other research suggests this will also increase the chances of headaches (Richter et al 2014).
This serves to remind clinicians that we need to be especially mindful of the words we use and the way we frame the delivery of information to avoid undermining the benefits of our interventions. It also raises the role of the patient in recognising some of these unintentional messages so we can have the opportunity to consciously reject their nocebo effect.