Although it’s common for clinicians to quell anxiety in patients by reassuring them that their symptoms are normal, the results of a new series of experiments found that such normalization was linked to a reduction in treatment-seeking. Patients who were reassured about their condition were more likely to tolerate their symptoms than to seek to resolve them.

“Healthcare providers may believe normalization will reduce patients’ anxiety and serve as a vicarious signal that others have come through the same experience, bolstering patients’ self-efficacy and, therefore, their motivation to act,” wrote Seyi Lawal and her colleagues. “However, we propose that normalizing symptoms may risk unintentionally influencing patients’ perceptions of both descriptive treatment norms (how most people manage their symptoms) and injunctive treatment norms (how one ought to manage their symptoms).”

Lawal is a PhD candidate in behavioral marketing at the Rady School of Management at the University of California, San Diego.

The study was published online in Nature Human Behaviour.

The investigators wrote that they based their study of the impact of normalization on treatment-seeking on the theory of planned behavior, which describes how one’s intention to act is influenced by one’s attitude toward the behavior.

People often look to others’ statements or behaviors to establish the norm, Lawal and her co-authors wrote. “While normalization statements provide no information about actual treatment norms, people may infer that their healthcare provider intends to communicate that most people suffering from the same symptoms do not pursue treatment” or that they should not pursue treatment.

The investigators also described the “normalcy paradox.” Namely, by normalizing symptoms, clinicians are seen to be pointing out their high prevalence.

“Experimental studies have found highlighting an issue’s prevalence results in inferences that the issue causes less harm,” Lawal and her colleagues wrote. This could also explain a reduced inclination toward treatment.

To test whether normalization correlated with a reduction of treatment-seeking — specifically — that people infer providers normalize symptoms to communicate that treatment is not warranted, Lawal and colleagues undertook a series of experiments to test the impact of these two statements.

“What you’re experiencing, while challenging, is actually very common — many people experience this;” and “I know this feels overwhelming, but I want to reassure you that these symptoms are normal, and most people experience them at some point in their lives.”

The researchers found that lay participants rated the two statements as normalizing rather than giving a directive for treatment. The mean for the perceived normalization of the first statement was 6.1 on a Likert scale, with an SD of 1.47. The mean for the second statement was 6.39, with an SD of 1.09.

Next, Lawal and her co-authors surveyed clinicians to determine whether the two normalization statements would be used to respond to a patient presenting with typical age-related complaints. A description of an encounter between a woman with symptoms of menopause and her clinician was used.

The clinicians who chose a normalizing statement were then asked how they anticipated their statement would influence the patient’s outlook, level of candor about condition, and the likelihood they would subsequently seek treatment for their symptoms.

About two thirds (62%) of clinicians responded with at least one normalizing statement (122/197; 95% CI, 54.98%-68.42%). Among clinicians who used normalization, 84% believed the statements would improve the patient’s outlook on their condition, whereas 82% indicated the statements would increase the patient’s willingness to talk more openly about their condition. Only 15% of clinicians surveyed (95% CI, 9.46%-21.66%) said that their response would decrease treatment-seeking in the patient.

For another experiment, Lawal and colleagues focused on the responses specifically of primary care physicians, including ob/gyns, with the expectation that their established patient-physician relationships would lead to less normalizing. However, the investigators still found that 43% of physicians used one of the normalizing statements in their response (91/210; 95% CI, 36.81%-50.10%).

The physicians justified their normalizing responses in terms of either wanting to reduce their patient’s anxiety, to reassure the patient that they were not alone, or to communicate that others had effectively treated the same symptoms. Only 9% of these doctors (95% CI, 5.21%-16.50%) believed that their response would decrease the patient’s likelihood of pursuing treatment. The modal response across all physicians was that the statement would increase the patient’s likelihood of pursuing treatment (46.2%).

For another experiment, Lawal and colleagues surveyed 400 laypersons to learn how often patients experience normalization by their clinician and which symptoms tended to be normalized. A total of 29% of participants reported having had a normalization experience at a recent medical appointment. Among the top presentations normalized were pain, reproductive health concerns, headaches and migraines, and respiratory symptoms.

For a further experiment, participants were given a vignette about a hypothetical friend with menopause symptoms who goes to see a doctor. In the scenario, the doctor is depicted using one of the two normalizing statements before offering the theoretical patient two options: seek treatment or live with the symptoms.

Based on the vignette, participants were asked to rate their inclination to seek treatment. A linear regression of treatment inclination found that when symptoms were normalized, participants were less likely to comply with treatment (P < .001).

Another experiment measured participants’ perceptions of how severe a dentist believed the symptoms to be in a dental pain scenario and whether they necessitated treatment. Normalization significantly reduced participants’ evaluation of the dentist’s level of support for treatment (P < .001) and the dentist’s assessment of the symptoms’ severity (P < .001). However, the dentist’s treatment support remained a positive predictor (P < .001), whereas perceived severity did not (P = .681). After accounting for both mediators, the direct effect of normalization on treatment inclination was not significant (P = .469).

Lawal and her co-investigators also tested what happened when the dentist did not normalize symptoms but emphasized the high prevalence of dental pain that others with the condition experience.

Participants in the prevalence condition perceived dental pain to be significantly more prevalent than participants in the normalization condition (P < .001) and the control condition (P < .001).

“A remark meant to reassure and promote self-efficacy can backfire and unintentionally demotivate action. To these patients, normal may not just mean prevalent, it means acceptable,” Lawal and her colleagues wrote.

“This process of ‘normalization,’ while attempting to reassure the patient, does not address whether the symptoms are impeding their daily function or activities of daily living, nor does it provide education and options to treat the presenting symptoms or, at least, help manage them within the context of their unique support system and resources,” said Douglas Spotts, MD, family physician in Mifflinburg, Pennsylvania, and board director of the American Academy of Family Physicians.

Spotts said that validating patient concerns through attentive listening, normalizing only when indicated, and helping patients preserve agency are steps the article indicated will best serve patients.

“The deeper lesson here is that reassurance should reduce fear without reducing legitimacy,” Spotts wrote.

Lawal and Spotts had no conflicts of interest.