Balint Journal 2025; 26(01): 14-21
DOI: 10.1055/a-2509-4172
Originalarbeit

Erwartungseffekte im psychosozialen Behandlungskontext: Mechanismen und klinische Implikationen von Placebo- und Noceboeffekten beim Bauchschmerz

Expectation effects in the psychosocial treatment context: Mechanisms and clinical implications of placebo and nocebo effects in abdominal pain
Sigrid Elsenbruch
1   Abteilung für Medizinische Psychologie und Medizinische Soziologie, Medizinische Fakultät der Ruhr-Universität Bochum, Bochum
2   Klinik für Neurologie, Center for Translational Neuro- and Behavioral Sciences, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen
,
Martin Teufel
3   Klinik für Psychosomatische Medizin und Psychotherapie, LVR-Universitätsklinik Essen, Universität Duisburg-Essen, Essen
› Author Affiliations

Zusammenfassung

Die Bedeutung von Behandlungserwartungen in der Therapie wird zunehmend anerkannt, insbesondere bei körperlichen Symptomen wie Schmerzen. Die Placeboforschung untersucht die Mechanismen und klinischen Implikationen dieser Erwartungseffekte für verschiedene Organsysteme und Krankheiten, wobei die Schmerzforschung umfangreiche Erkenntnisse liefert. Sowohl experimentelle als auch klinische Ergebnisse zeigen, dass Kognitionen und Emotionen die Symptomwahrnehmung erheblich beeinflussen können, wie die Placebo-Analgesie und Nocebo-Hyperalgesie zeigen. Placebo- und Nocebo-Effekte werden bei verschiedenen Schmerzarten und -erkrankungen beobachtet, unabhängig von der Schmerzlokalisation oder der spezifischen Diagnose. Sie sind besonders relevant für Bauchschmerzen und interozeptive Symptome, die in der Psychosomatischen Medizin und der Klinischen Psychologie häufig vorkommen. Das Verständnis dieser Effekte ist für die Behandlung somatoformer Störungen wie dem Reizdarmsyndrom von entscheidender Bedeutung. Die Forschung in diesem Bereich zielt darauf ab, Wissenslücken zwischen verschiedenen Disziplinen zu schließen, was wertvolle klinische Auswirkungen hat und den Weg für bessere Präventions- und Behandlungsstrategien ebnet. In dieser Übersichtsarbeit werden (1) grundlegende Mechanismen und Forschungsansätze zu Placebo- und Nocebo-Effekten, (2) Erkenntnisse zu Placebo-Effekten bei Bauchschmerzen und interozeptiven Symptomen, (3) evidenzbasierte Schlussfolgerungen und praktische Empfehlungen für die klinische Umsetzung sowie (4) Erkenntnisse und umsetzbare Vorschläge für BehandlerInnen und Betroffene dargestellt. Behandlerinnen und Behandler können Wissen aus der Placeboforschung praktisch nutzen, indem sie beispielsweise eine vertrauensvolle Beziehung aufbauen, positive Informationen gezielt in den Vordergrund stellen und Behandlungen systematisch wertschätzen und gleichzeitig Nocebo-Effekte strategisch minimieren, indem sie die negativen Vorerfahrungen der Patienten verstehen und die Kommunikation verbessern, um Missverständnissen, negativen Erwartungen und Ängsten bestmöglich vorzubeugen.

Abstract

The significance of treatment expectations in therapy is increasingly acknowledged, particularly regarding bodily symptoms like pain. Placebo research investigates the mechanisms and clinical implications of these expectation effects across various organ systems and diseases, with pain research providing extensive insights. Both experimental and clinical findings show that cognitions and emotions can significantly influence pain perception, as demonstrated by placebo analgesia and nocebo hyperalgesia. Placebo and nocebo effects are observed across different pain types and disorders, regardless of pain location or specific diagnosis. They are particularly relevant for abdominal pain and interoceptive symptoms common in psychosomatic medicine and clinical psychology. Understanding these effects is crucial for treating somatoform disorders like irritable bowel syndrome (IBS). Research in this area aims to bridge knowledge gaps across disciplines, offering valuable clinical implications and paving the way for better prevention and treatment strategies. This review outlines (1) fundamental mechanisms and research approaches to placebo and nocebo effects, (2) findings on placebo effects in abdominal pain and interoceptive symptoms, (3) evidence-based conclusions and practical recommendations for clinical implementation, and (4) insights and actionable proposals for healthcare providers and patients. Healthcare providers can strategically harness placebo effects through positive information, enhanced treatment value, and empathetic relationships, while also addressing nocebo effects by understanding patients' negative prior experiences and improving communication to reduce misunderstandings and negative expectations. A trusting collaboration between providers and patients is essential for long-term therapeutic success.



Publication History

Article published online:
09 April 2025

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  • References

  • 1 Enck P, Bingel U, Schedlowski M. et al. The placebo response in medicine: minimize, maximize or personalize?. Nat Rev Drug Discov 2013; 12: 191-204
  • 2 Raja SN, Carr DB, Cohen M. et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain 2020; 161: 1976-1982
  • 3 Treede RD, Rief W, Barke A. et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain 2019; 160: 19-27
  • 4 Beecher HK. Pain in Men Wounded in Battle. Ann Surg 1946; 123: 96-105
  • 5 Beecher HK. The powerful placebo. J Am Med Assoc 1955; 159: 1602-1606
  • 6 Benedetti F. Placebo and the new physiology of the doctor-patient relationship. Physiol Rev 2013; 93: 1207-1246
  • 7 Bingel U, Wanigasekera V, Wiech K. et al. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med 2011; 3: 70ra14
  • 8 Eippert F, Finsterbusch J, Bingel U. et al. Direct evidence for spinal cord involvement in placebo analgesia. Science 2009; 326: 404
  • 9 Tinnermann A, Geuter S, Sprenger C. et al. Interactions between brain and spinal cord mediate value effects in nocebo hyperalgesia. Science 2017; 358: 105-108
  • 10 Kessner S, Forkmann K, Ritter C. et al. The effect of treatment history on therapeutic outcome: Psychological and neurobiological underpinnings. PLoS One 2014; 9: e109014
  • 11 Zunhammer M, Ploner M, Engelbrecht C. et al. The effects of treatment failure generalize across different routes of drug administration. Sci Transl Med. 2017 9. eaal2999
  • 12 Kampermann L, Tinnermann A, Büchel C. Generalization of placebo pain relief. Pain 2021; 162: 1781-1789
  • 13 Weng L, Peerdeman KJ, Della Porta D. et al. Can placebo and nocebo effects generalize within pain modalities and across somatosensory sensations?. Pain 2022; 163: 548-559
  • 14 Strigo IA, Bushnell CM, Boivin M. et al. Psychophysical analysis of visceral and cutaneous pain in human subjects. Pain 2002; 97: 235-246
  • 15 Koenen LR, Icenhour A, Forkmann K. et al. Greater fear of visceral pain contributes to differences between visceral and somatic pain in healthy women. Pain 2017; 158: 1599-1608
  • 16 Van Oudenhove L, Kragel PA, Dupont P. et al. Common and distinct neural representations of aversive somatic and visceral stimulation in healthy individuals. Nat Commun 2020; 11: 5939
  • 17 Koenen LR, Pawlik RJ, Icenhour A. et al. Associative learning and extinction of conditioned threat predictors across sensory modalities. Commun Biol 2021; 4: 553
  • 18 Icenhour A, Petrakova L, Hazzan N. et al. When gut feelings teach the brain to fear pain: Context-dependent activation of the central fear network in a novel interoceptive conditioning paradigm. Neuroimage 2021; 238: 118229
  • 19 Wolf S. Effects of suggestion and conditioning on the action of chemical agents in human subjects; the pharmacology of placebos. J Clin Invest 1950; 29: 100-109
  • 20 Elsenbruch S, Enck P. Placebo effects and their determinants in gastrointestinal disorders. Nat Rev Gastroenterol Hepatol 2015; 12: 472-485
  • 21 Sperber AD, Morris CB, Greemberg L. et al. Development of abdominal pain and IBS following gynecological surgery: a prospective, controlled study. Gastroenterology 2008; 134: 75-84
  • 22 Lieberman MD, Jarcho JM, Berman S. et al. The neural correlates of placebo effects: A disruption account. Neuroimage 2004; 22: 447-455
  • 23 Price DD, Craggs J, Nicholas Verne G. et al. Placebo analgesia is accompanied by large reductions in pain-related brain activity in irritable bowel syndrome patients. Pain 2007; 127: 63-72
  • 24 Lu HC, Hsieh JC, Lu CL. et al. Neuronal correlates in the modulation of placebo analgesia in experimentally-induced esophageal pain: A 3T-fMRI study. Pain 2010; 148: 75-83
  • 25 Schmid J, Theysohn N, Gaß F. et al Neural mechanisms mediating positive and negative treatment expectations in visceral pain: A functional magnetic resonance imaging study on placebo and nocebo effects in healthy volunteers. Pain 2013; 154: 2372-2380
  • 26 Schmid J, Langhorst J, Gaß F. et al. Placebo analgesia in patients with functional and organic abdominal pain: a fMRI study in IBS, UC and healthy volunteers. Gut 2015; 64: 418-427
  • 27 Lee HF, Hsieh JC, Lu CL. et al. Enhanced affect/cognition-related brain responses during visceral placebo analgesia in irritable bowel syndrome patients. Pain 2012; 153: 1301-1310
  • 28 Placebo Competence Team. Bingel U. Avoiding nocebo effects to optimize treatment outcome. JAMA. 2014; 312: 693-694
  • 29 Klinger R, Stuhlreyer J, Schwartz M. et al. Clinical Use of Placebo Effects in Patients With Pain Disorders. Int Rev Neurobiol 2018; 139: 107-128
  • 30 Hansen E, Zech N, Benson S. [Nocebo, informed consent and doctor-patient communication]. Nervenarzt 2020; 91: 691-699
  • 31 Häuser W, Hansen E, Enck P. Nocebo phenomena in medicine: their relevance in everyday clinical practice. Dtsch Arztebl Int 2012; 109: 459-465
  • 32 Aulenkamp J, Steinmüller K, Icenhour A. et al. [From gut feeling to visceral pain: Effects of negative expectations in the context of the gut-brain axis]. Schmerz 2022; 36: 182-188
  • 33 Evers AWM, Colloca L, Blease C. et al. on behalf of the Consortium of Placebo Experts. What Should Clinicians Tell Patients about Placebo and Nocebo Effects? Practical Considerations Based on Expert Consensus. Psychother Psychosom 2021; 90: 49-56
  • 34 Kaptchuk TJ, Kelley JM, Conboy LA. et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ 2008; 336: 999-1003
  • 35 Kaptchuk TJ, Friedlander E, Kelley JM. et al. Placebos without deception: A randomized controlled trial in irritable bowel syndrome. PLoS One 2010; 5: e15591
  • 36 Lembo A, Kelley JM, Nee J. et al Open-label placebo vs double-blind placebo for irritable bowel syndrome: a randomized clinical trial. Pain 2021; 162: 2428-2435
  • 37 Waber RL, Shiv B, Carmon Z. et al. Commercial features of placebo and therapeutic efficacy. JAMA 2008; 299: 1016-1017
  • 38 Fehse K, Maikowski L, Simmank F. et al. Placebo Responses to Original vs. Generic ASA Brands During Exposure to Noxious Heat: A Pilot fMRI Study of Neurofunctional Correlates. Pain Med 2015; 16: 1967-1974
  • 39 Petrie KJ, Rief W. Psychobiological Mechanisms of Placebo and Nocebo Effects: Pathways to Improve Treatments and Reduce Side Effects. Annu Rev Psychol 2019; 70: 599-625