‘This Doesn't Look Good': Such Words Can Worsen Patient Pain

Medscape

7 days ago

Negative expectations are more persistent and more potent than placebo effects, according to a recent study led by Ulrike Bingel, MD, PhD, professor of clinical neuroscience and director of Interdisciplinary Centre for Pain Medicine at University Hospital Essen, Germany. Bingel and her research team found that negative expectations intensify pain more significantly and with greater lasting impact than positive expectations help relieve it.
In the study, Bingel and colleagues tested 104 healthy volunteers who were exposed to short-term heat pain. On average, participants rated their pain 11 points higher when primed with negative expectations compared with a control condition.
In an interview with Medscape's German edition , Bingel — also spokesperson of the Collaborative Research Center "Treatment Expectation" — explains how clinicians can better communicate with patients to improve outcomes and avoid common pitfalls. Her team has also developed practical communication resources for healthcare providers and patients.
Your study shows that negative expectations influence pain perception more strongly and persistently than positive beliefs. Was that the outcome you anticipated?
Yes, that was in fact our hypothesis. A smaller prior study had already suggested that nocebo effects — that is, effects driven by negative expectations — are easier to trigger than placebo effects. In an earlier study, we also showed that memories of negative events form more readily and endure longer than positive ones. So, the findings align with each other and support what could be described as an evolutionary 'better safe than sorry' strategy.
How should physicians ideally inform patients about a treatment?
There are many ways to approach this, depending on the patient's individual needs and preferences. But what's crucial is that patients understand what the treatment is for and what outcomes they can expect. What benefit does it offer me? What's the intended goal? While this may sound straightforward, many patients only know the number of pills to take and when — perhaps their shape or color — but very few understand what the medications are meant to achieve or how they work. Unfortunately, package inserts don't help much with that either.
So, the first step is always to explain the treatment objective clearly, why it is the best choice for that patient, and when they can expect it to start working. From there, many communication strategies can be personalized. The key is to help patients begin treatment with clarity and as little anxiety as possible.
Should patients be told that negative expectations are more powerful than positive ones?
I'm not aware of any studies that specifically address that question. However, we do know that simply educating patients about the nocebo effect can help reduce both the incidence and severity of adverse effects.
You recommend avoiding unintentionally negative phrasing. Can you give a few classic examples?
The list is practically endless. Just think about what might sound unsettling to you. Phrases like, 'Whew, that doesn't look good,' or 'I really don't know what else to try,' or 'There's nothing we can do,' are all problematic. Even something like, 'You're a high-risk patient,' said ahead of a necessary surgery, can be discouraging. A more reassuring alternative would be, 'We'll take every measure to support you through this operation, even with your preexisting conditions.'
I believe communication missteps begin when we lose sight — even briefly — of how powerful our words can be. That's easy to do in the stress of daily clinical practice. But precisely in those moments, it's our responsibility to stay composed, create a secure conversational space, and communicate in a way patients can receive with trust and minimal anxiety.
Regarding shared decision-making, patients increasingly want to be involved in treatment decisions. How do you view this in light of your findings? Should patients, for example, be discouraged from reading the package insert too closely?
We know that shared decision-making is helpful, even from a placebo and nocebo perspective. That's particularly true when there aren't too many competing treatment options. An overload of choices can be confusing or even distressing. But when the clinical guidelines support options A, B, or C equally, involving patients in the choice is beneficial. The option they trust more will have a psychological edge.
Where that trust comes from differs for each person. Maybe the drug's mechanism of action feels more intuitive to them. Maybe they know someone who did well on it. Or maybe they overheard something positive during morning rounds. That doesn't really matter. What matters is that, in my view, patient preferences should always be considered — within the boundaries of evidence-based, guideline-compliant care.
To what extent are your findings transferable to clinical settings? Are further studies planned?
I'm convinced that the effects we observed in healthy volunteers likely underestimate what happens in clinical practice. Many medical scenarios — whether evaluating acute symptoms, delivering a new and possibly serious diagnosis like cancer, or managing chronic illnesses with limited treatment options — are inherently anxiety-provoking and often accompanied by fear and negative expectations. We know from research that all of this fuels nocebo effects.
There's already a substantial body of evidence showing that a significant proportion of adverse effects seen in routine clinical care are driven by nocebo responses. The next step in research isn't to confirm this effect again, but to test targeted therapeutic strategies aimed at minimizing or even preventing nocebo effects in day-to-day care. Doing so could make treatments more effective and better tolerated and help ensure that patients don't avoid essential medications due to fear.