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Nocebo versus sugar-coating: the pros and cons of colourful descriptions of painful problems

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

“It’s just bone-on-bone in there.”

“Your intervertebral disc has slipped.”

All women over 50 have bad shoulders, that's just how it is.”

“Keep going like you are and that tendon is going to rupture.”

“You’re hip was butchered by your last surgeon.”

I’m glad it’s not me!

“Your core is weak.”

“You’ll never play tennis with this shoulder again.”

“That meniscus is shredded.”

“You’re only 20, but you have the back of an 80-year-old.”

“I’ve never seen anything like this before!”

And so on.

Those are some typical examples of “nocebic” statements in musculoskeletal medicine: harmful exaggerations that make problems sound worse than they are, setting patients up for “pain catastrophizing” — excessive pessimism about the meaning of pain. For a good introduction to the problem of nocebo, Dr. Howard Luks rails against “bone-on-bone” in particular.

This post is a little different. Could such language still have its place? What exactly is and is not actually the problem with colourful descriptions of problems? Shouldn’t healthcare professionals describe problems candidly and clearly, even at the risk of making them sound too awful? Or should they always try to apply a coat of sugar, and avoid scaring patients at all costs?

I revised and expanded this post a few times before putting it out there (I don’t want to admit how many), and I think it’s still much more of a conversation starter than a mic drop… although I do quite like my final point. Feedback is always welcome, but more so on this one than most.

Nocebo … maybe not so bad?

Nocebo is the opposite of placebo: making symptoms worse through the power of the mind, rather than better. And entirely subjective symptoms like pain — all tangled up with our emotions — might be the most vulnerable to this. We should avoid scaring people just because it’s not nice, but does being spooked actually make pain worse?

Nocebo is the same idea as induced all-in-your-head pain, and putting it that way exposes its serious weaknesses (see “Can the mind create pain?”). Telling people they are in pain because of their mental state is a dick move, most of all because it might just not be true. The power of placebo is generally overrated, even its ability to ease fully subjective symptoms like pain — relief tends to be fairly brief and temporary — and so the power of nocebo could be just as overrated.

It’s a near certainty that nocebo can increase anxiety, but not necessarily pain itself — or not that much.

On the other hand, there are many potential harms of nocebo

On the other hand, there are also good reasons to think that nocebo can indeed amplify pain. There is a mountain of evidence that inflated pessimism about pain — “catastrophisation,” as in “this knee thing is going to be a catastrophe!” — is linked to more pain and terrible outcomes. And what could possibly cause more pessimism than a healthcare professional exaggerating the seriousness of a problem?

(Catastrophisation research is well summarized by Sullivan and Tripp, with lots of references, in their defense of it as a useful technical concept). They also point out that the term “catastrophisation” should never actually be used with patients, because it’s scary and/or potentially dismissive and blamey. The first rule of catastrophisation club is … you don’t talk about catastrophisation club!)

There are some more roundabout ways nocebo might do its dirty work. For instance, permanently and significantly undermining someone’s confidence in movement, by convincing them that they are more fragile than they actually are … not exactly a win!

I remain unsure whether pain-causing nocebo is a real phenomenon. The more I read, the less sure I feel. But perhaps it’s best to apply the precautionary principle.

Forbidden language

It has been fashionable for years now to scold healthcare professionals who dare to use language that could be misconstrued as scary, intimidating. For instance, I have heard many complaints about my description of tendinitis as “tendon rot.” Is there actually a risk that I will make people with tendinitis worse off with that kind of talk? Dare we describe health problems creatively and evocatively?

Or should we always be “politically correct” with clinical communication, always looking — and maybe straining — to find harmless ways of explaining everything, even things that are genuinely serious? Which often involves a lot of extra verbiage to avoid much simpler but “scarier” ways of saying things, like so:

“Your tendon has undergone widespread microscopic changes that may indicate that it isn’t as structurally sound as it could be right now.”

Doesn’t exactly roll of the tongue, does it? And I don’t think it’s really fooling anyone, either. People can smell “sugar coating” B.S. from a mile away. When I originally shared a shorter, simpler version of this post on Facebook, reactions were emphatically anti-sugar-coating. People do not like being handled with kid gloves — or at least we don’t like knowing it. Like diplomacy, it’s probably most effective when it doesn’t sound like diplomacy.

Word shielding gone mad?

Physical therapist David Poulter calls verbal contortions like this “word shielding gone mad.” Sugar coating clinical reality can easily tip over into being insipid, paternalistic, and confusing. If you think nocebo is bad, wait’ll you see how a bit of paternalism can nuke trust and rapport! (And how bad is that? How much does that “scare” people?)

We cannot actually avoid the spectre of nocebo by sugar-coating pathology and injury or refusing to use plainer English. If a problem is actually intimidating and difficult, patients are going to figure that out. Maybe it’s better to focus on rapport and clarity. Demonizing specific terminology and imagery is doomed, because how demonic they are depends heavily on context and tone, and whimsy and even colourful imagery can be invaluable facets of communication and education. As David put it: “even so-called taboo words have limited power in context… and are a part of communication and empowering patients.”

Spooking patients? Probably bad. Though perhaps not actually pain-causing.

Empowering them? Definitely good!

And whether it goes one way or the other depends more on the subtleties of delivery than specific words. How much trouble they cause depends greatly on how and why they are used, and with whom, and what other ideas they are delivered with. The difference between nocebo and just good communication could be as subtle as wink or a rueful laugh.

Maybe lying is the real problem

The question here, I think, is not whether it’s okay to scare people — obviously it’s not — but whether candid and effective descriptions of problems are actually scary in the first place. I doubt they are, if they are considerately tuned to the sensibilities of the patient; if they come across as pragmatic, engaging, realistic; if they are truthful and earnestly educational in spirit.

Terms like “slipped disc” are not the enemy — ignorance and exaggeration are the enemies. The problem with some of the nocebic statements at the top of the post is not that the language is scary, but that they are scary lies told to pathologize people for profit, to inflate the perceived need for treatment and the prestige of the clinician.

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