Nocebo and pain: adverse effects of excessive information

Abstract

Information to patients about their disease, especially about persistent pain, is important clinical practice approach. Improving (placebo) or worsening (nocebo) expectations may influence patients' evolution during treatment. The interest on this topic has increased the number of studies on behavioral and neurophysiologic bases of placebo and nocebo effects. Placebo effect is related to a change in patients' clinical status attributed to an event, object or behavior in the therapeutic environment 1 . In general, placebo effect is always present in the clinical practice and may be defined as an inert effect within a positive context. If the context is negative, there is the opposite phenomenon, the nocebo effect, which creates negative expectations and worsens health status 2 . Nocebo effect may be defined as a set of events produced by negative expectations during therapeutic process 2,3 . The word nocebo was created to define negative responses observed in placebo-treated groups 4 . Factors as environment (office, clinic, hospital), professional-patient relationship, verbal suggestions and patients' context (expectations, explicit memories, beliefs, emotions) may influence clinical results, thus cannot be ignored 2,5 . Nocebo effect may increase pain intensity (hyperalgesia or induced allodynia), stress, anxiety, catastrophizing, in addition to increasing the search for health services, new therapeutic approaches, higher drug consumption and more surgeries to treat adverse effects produced by nocebo effect itself 5 . For example, excessive imaging exams for information about diagnosis and prognosis in chronic unspecific musculoskeletal conditions (such as low back pain, cervical pain, osteoarthritis) or disclosure of clinical results using medical jargons or specific technical terms, may negatively contribute and produce unnecessary attitudes and beliefs 5 . These approaches favor nocebo effect and may be considered iatrogenic, favoring worsening of pain, limitation of activities, development of negative expectations, anxiety, catastrophizing, avoidance and pain-related fear 4 . Health education process itself may also contribute for the development of nocebo effect in people with persistent pain 6 . Nocebo responses may be manifested by negative verbal suggestions by professionals (such as in communicating diagnosis, therapeutic risks, prognosis and verbal interaction during treatment), by social learning (such as negative media campaigns) or by observation (experiences of others) 3 . Education models based exclusively on biomedical information contribute for nocebo effect development 7 . Maladaptive beliefs developed by patients may be exacerbated by poor professional-patient relationships, low heath services quality, by the media or even by individual experience and primarily include causal relations attributed to pain 7,8 . Pain amplification, as well as amplification of other emotional components present in the nocebo effect, seems to be related to the activation of brain affective-cognitive pathways 8 ....

The Impact of Low Back Pain on the Quality of Life of Children between 6 and 12 Years of Age

“…This occurred mainly because the study addressed low back pain in children, thus making the exclusive use of imaging tests infeasible. Moreover, it was also sought to prevent the nocebo effect, which tends to worsen participants’ health status when they receive a diagnosis through imaging exams [ 59 , 60 , 61 ] and leads to their increased use of medication, thus “catastrophizing” the pain [ 59 ]. Finally, even though the number of participants was almost 20% higher than the calculated minimum sample size, it is important to note that roughly only one-third of the eligible participants took part in the study.…”

Prevalence of Low Back Pain and Associated Risks in School-Age Children

“…However, as in another recent study ( Bernardes, Gómez-Salgado et al, 2019 ), all evaluations and examinations were standardized to minimize the risk for bias. Another possible limitation may have been the use of reported LBP complaints, but besides being a study involving children, LBP diagnosis by imaging tests is unnecessary and undesirable at any age ( Fagundes et al, 2016 ).…”

Untitled

“…Hence, it is up to the health professionals to make daily efforts searching for better therapeutic experiences for their patients. [31] Clinicians, in their daily practice, should be aware that their presence in the therapeutic relationship has agency over and above the effects of the drugs they use or the procedures they perform. This is of paramount importance since it is a reminder that the context in which medical care is delivered influences important patient outcomes including treatment compliance, the experience of adverse effects, and the efficacy of our care.…”