Editorial: nocebo effects and negative suggestions in daily clinical practice, forms, impact, and approaches to avoid them

Key points

1. 01Nocebo effects from negative communication are real and physiologically measurable, not imagined
2. 02Announcing a treatment with positive meaning significantly increases its therapeutic effect compared to silent or hidden administration
3. 03Risk information for informed consent can itself cause the side effects it describes, and how it is framed matters greatly
4. 04Patients under medical stress enter a natural trance-like state of heightened suggestibility, making them especially vulnerable to casual negative remarks
5. 05A framework of therapeutic communication covers company, comfort, control, care, information, respect, safety, and healing as core topics

How it was conducted

Design

Narrative review with illustrative clinical examples and structured literature searches

Topic

Nocebo effects, negative suggestions, and therapeutic communication in daily clinical practice

Literature searches

PubMed searches on '(informed consent) AND nocebo' and 'hypnosis AND placebo' yielding targeted subsets of relevant articles

Clinical domains covered

Emergency medicine, surgery, anesthesia, pain therapy, pediatrics, psycho-oncology, and informed consent

What they found

• Hidden (unannounced) intravenous metamizol produced significantly lower analgesia than open (announced) application, illustrating the additive placebo component of treatment announcement (Benedetti, 2013)
• Dentists who announced nitrous oxide as a drug that enhances sensitivity abolished its analgesic effect (Dworkin et al., 1983)
• A muscle relaxant announced as a stimulating agent increased tension instead of causing relaxation (Flaten et al., 1999)
• Ipecac, a drug used to induce vomiting, reduced nausea and vomiting in pregnant women when announced as an antiemetic (Wolf, 1949)
• Objective dynamometry showed significant weakening of maximal arm muscle strength after risk information about a pain catheter; the reduction was absent when benefits were communicated alongside the risks (Zech et al., 2019)
• Using a comfort scale rather than a pain scale after caesarean section resulted in significantly lower pain scores at rest and in movement, and less demand for analgesics (Chooi et al., 2013)
• Levinson (1965) demonstrated recall and reactions to negative suggestions given during surgery under general anesthesia in 4 out of 10 patients in a simulation experiment

Limitations

• The article is a narrative review and does not perform a systematic meta-analysis, so selection bias in example choice is possible
• Many cited studies are small, older, or come from experimental rather than routine clinical settings
• Specific effect sizes for communication interventions in routine clinical care are rarely reported in the cited literature
• The natural trance and hypnosis model is theoretical and mechanistic evidence remains incomplete

Why it matters

For patients

The words your doctor and nurse use around you genuinely affect your pain, side effects, and recovery, so you can expect and request empathetic, positively framed communication during any medical encounter.

For clinicians

Every clinical interaction - including silent procedures, informal bedside conversation, and risk disclosure - carries the potential to generate nocebo harm or placebo benefit, making therapeutic communication a core clinical skill rather than a soft extra.

For readers

This review synthesises the evidence that language and relationship quality are pharmacologically active components of healthcare delivery, with a practical framework for transforming routine clinical communication.