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13 Articles in Volume 18, Issue #3
Anger Expression & Chronic Pain
Ask the Expert: Should reliance on gabapentin/pregabalin be limited?
Chronic Pain in Children
Considering Comorbidities When Selecting Medications for Chronic Pain Management (Part 1)
Dousing the Physician Burnout Epidemic: An AMA Perspective
Harnessing the Power of Words
Inside ASRA with David Provenzano, MD
Management of Intrathecal Therapies by Interprofessional Teams
Nurse Burnout in Pediatric Pain Management: A Model and Pilot Intervention
Physician Burnout: An Oldtimer’s View
Reporting Metrics, Media Coverage...Letters from the Minds of Peers and Patients
The Case for Slow-Release Anesthetics
The Impact of Pain Practice

Harnessing the Power of Words

How the presentation of language may allay patients’ pain experience

One reason for variability in a patient’s symptoms may have to do with the individual’s underlying thoughts, beliefs, and ideas—all of which have the potential for amplifying pain symptoms and bodily distress. The specific words used by clinicians to prepare patients for a procedure or to help them understand a treatment plan, therefore, may significantly affect a patient’s experience of pain.

In a study of 140 women receiving epidural anesthesia or spinal anesthesia for childbirth, those who anticipated pain because they were told the intradermal injection of a local anesthetic would “feel like a bee sting” and would be “the worst part of the procedure” reported significantly more pain (P < 0.001) than those who were told the anesthetic would “numb the area” and that they would “be comfortable during the procedure."1 Using gentler, more reassuring words seemed to improve the patient’s experience during the invasive procedure.

The iatrogenic potential of a physician’s words is powerful, and careless communication could amplify what may be a relatively benign occurrence into a source of extreme anxiety, according to a paper written by Arthur J. Barsky, MD, professor of psychiatry at Harvard Medical School, and vice chair for academic affairs in the psychiatry department at Brigham & Women’s Hospital, in Boston.2

Know When Knowledge Amplifies Symptoms

The mechanism for explaining how information affects a patient’s perception of symptoms is called viscerosomatic amplification.3 The information conveyed by the physician does not necessarily cause somatic symptoms, but may amplify symptoms produced by underlying medical issues, including common benign dysfunctions, transient and self-limited ailments, stressful life events, lack of exercise, insufficient sleep, or dietary indiscretions.

In addition to enhancing the experience of pain, viscerosomatic amplification may occur in a variety of clinical scenarios. Patients taking medications, for example, often experience adverse, nonspecific side effects that are not a direct result of the specific pharmacological action of the drug.4 When a new medication regimen is initiated, the simple knowledge of potential nonspecific or ambiguous adverse effects, such as fatigue, nausea, or dizziness, may increase the frequency with which the effects are experienced and reported.

Studies have shown that patients who learned about a medication’s adverse effects, either through discussion with their physician or as part of giving informed consent, experienced more of those effects than patients who were not informed. In a study of 76 patients who received beta-blocker treatment for hypertension, 32% of the 38 patients who were informed of the possibility of erectile dysfunction experienced this adverse effect.5 However, only 13% of the 38 patients who were not specifically warned experienced this side effect.5 Similarly, in a large double-blind trial of statins, the incidence of muscle-related side effects increased from 1% to 1.26% per year after patients (n = 9,899) were unblinded and given the active drug.6

The nocebo phenomenon, in which patients receiving placebos develop adverse effects, may shed some light on these results. Time and again, this phenomenon has demonstrated that patients randomized to receive placebo in controlled, double-blind clinical trials manifest similar adverse effects at a comparable frequency as patients receiving an active drug.4 Being told of their possible occurrence increases the odds that adverse effects will occur.

An increase in symptoms may also occur when test results of unknown clinical significance are shared with the patient. In a randomized study of acute low back pain, one group (n = 210) underwent spine imaging, while a control group (n = 211) did not. Both groups received conservative treatment for their pain. At three-month follow-up, patients in the imaging group reported significantly more pain, greater functional impairment, and more physician visits.7

According to Dr. Barsky’s paper, receiving new medical information such as a test result may set off a self-perpetuating cycle of symptom amplification. Similarly, learning that a symptom may be noteworthy seems to enhance it. Reattributing the symptom to a more serious source causes the patient to monitor it more closely, making the symptom appear more distressing and leading to thoughts and worries in the patient.3 The patient then looks for additional symptoms to corroborate the suspicion that something may be wrong, heightening his or her awareness of other ambiguous or transient symptoms that may have been previously ignored. The new symptoms are considered to be additional evidence of the seriousness of the condition, leading anxiety and catastrophization to spiral.

Avoid the Spiral Effect

Clinicians may employ several strategies, advised Dr. Barsky in his paper, to help avoid inadvertent potentiators of viscerosomatic amplification in pain patients. When conveying medical information, physicians may minimize patient distress by helping them explore their ideas about the symptoms at play. Answering questions about a suspected cause of a particular symptom, as well as its possible significance, its most troubling aspects, and its future course, may lead to a more realistic and reassuring discussion of the patient’s concerns.

“Information is an important mediator of the variability in the relationship between disease and symptoms,” said Dr. Barsky.2 “Its importance in ensuring optimal management of patient care must be understood by clinicians.”

Clinicians may also take time to describe the process of viscerosomatic amplification and the nocebo effect to their patients. Words should be chosen wisely when discussing potentially painful procedures, with emphasis placed on what will be done to alleviate pain or to give patients control over their analgesic regimen, as applicable. When explaining adverse effects of medications, physicians should focus on the proportion of patients who do not experience the effects and the benefits of the medication.

Physicians may further help patients by utilizing “contextualized informed consent” in the practice setting.8 In this approach, if the patient agrees, all serious and medically significant adverse effects are described, and while the patient is encouraged to report all troublesome symptoms, benign, nonspecific side effects are not disclosed in advance, as doing so may make them more likely to appear.

Last updated on: June 18, 2020
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