Nocebo Effects and Negative Suggestions in Daily Clinical Practice – Forms, Impact and Approaches to Avoid Them

Abstract

Medical situations are hot spots in the life of a patient with potentially long lasting effects arising from the use of either negative expressions or encouraging statements, or the lack of empathy or a positive physician-patient relationship. Health care personnel should be aware of and evaluate what patients are exposed to, hear and see. Knowing more about the effects of nocebos and negative suggestions, combined with increased attention to these matters, provides the basis for better recognition of detrimental influences in their own clinical environment and to be able to avoid, stop or neutralize them. After anamnesis patients should not be left with a focus on a negative past, but shifted to positive experiences prior to their illness, or to positive expectations in the future following surgery and rehabilitation. For example, after examining an injured leg the doctor should not turn to the computer for documentation unless he has shifted the patient’s focus on the other, unimpaired leg. “Is that painful too? No? Good! Can you feel that? Yes? Perfect! Can you bend that knee, move these toes? Great! That’s good.” This example draws attention to the fact that negative effects (discussed in the following) substantially are dependent on the focus of the patient and thus can be affected by focus shift and distraction. Patients, their symptoms and their healing are negatively affected by the omission of placebo effects, by nocebo effects and by negative suggestions.

Time-Dependent Negative Effects of Verbal and Non-verbal Suggestions in Surgical Patients—A Study on Arm Muscle Strength

“…Finally, in this study, suggestibility as tested with the HGSHS had an impact on the extent of the nocebo effect ( Figure 5). While this correlation is not always observed in placebo research, it may reflect the inclusion of a number of suggestions tested where factors other than conditioning and expectation play a role (Corsi and Colloca, 2017;Hansen and Zech, 2019). The very low regression coefficient confirms the observation that suggestibility is not a major determinant in clinical situations (Montgomery et al, 2011), and that suggestions have impact on all patients, not merely on highly suggestible subjects.…”

“…Thus, the described test system could be used for complex interactions of suggestions common in medical situations. Moreover, the tested and observed muscular weakening could be a marker for a more general "weakening effect" of nocebo suggestions and a common, clinically relevant "weakening" of patients in the medical setting (Hansen and Zech, 2019;Zech et al, 2019). It may correspond to and reflect weakening of complex basic physiological functions like homeostasis, recovery, or immune surveillance that are not easy or fast to measure and quantify.…”

Nocebo, Aufklärung und Arzt-Patienten-Kommunikation

“…Für ein patientenorientiertes und -verträgliches Gespräch sind neben Nocebo-Wirkungen auch viele andere Aspekte zu berücksichtigen [26]. So kann es sich letztlich negativ auswirken, wenn bei einer Behandlung nicht Placebo-Effekte genutzt werden [11].…”

“…Nocebo-Effekte können z. T. auch durch den gewählten Bezugsrahmen ("Framing") verringert werden, indem die Risikowahrscheinlichkeit positiv formuliert wird: "90 % der Patienten vertragen das Medikament gut" statt "Bei 10 % tritt eine Nebenwirkung auf " [2]. Dabei sollten Negationen ("Bei 90 % tritt diese Nebenwirkung nicht auf ", "Die meisten Patienten haben keine Schmerzen") vermieden werden, weil sich starke negative Suggestionen nicht mit einem "nicht" auslöschen lassen [11].…”

“…Durch Hinzunahme von Bedeutung kann sie Therapie und Nebenwirkungen wesentlich beeinflussen, d. h., sie wird zur "therapeutischen Kommunikation". Dafür sind ein bedachter Umgang mit Worten, Kenntnisse über die Wirkung von Suggestionen und Kommunikationsstrategien aus der Psychotherapie hilfreich [11,26]. Die zentrale Rolle der Bedeutung der kommunizierten Inhalte hat zu dem Vorschlag geführt, Placebo-und Nocebo-Effekte treffender als "meaning response" zu bezeichnen [17].…”