“Diagnosis Threat”: The Effect of Negative Expectations on Cognitive Performance in Head Injury
Abstract
The present study examined the effect of negative expectations on neuropsychological test performance. It was hypothesized that having attention called to a history of prior head injury and the potential effects of head injury on cognition would result in diminished neuropsychological test performance relative to individuals with a similar head injury history but who did not have their attention called to their head injury history ('diagnosis threat'). Of 36 participants with a history of mild head injury, 17 were randomly assigned to diagnosis threat and 19 to neutral test directions. The diagnosis threat group performed significantly worse on tests measuring general intellect and memory, but were not different from the neutral group in basic attention or psychomotor speed. The diagnosis threat group rated themselves as putting forth less effort on the neuropsychological battery, and self-rated effort correlated with test performance in that group. Overall, results serve as a reminder that neuropsychological tests are measures of behavior, and thus can be influenced by nonneurological factors.
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People associate concussion with negative outcomes and therefore experience a type of 'diagnosis threat'.
“This is thought to occur because people associate concussion with negative outcomes and therefore experience a type of “diagnosis threat” (Suhr & Gunstad, 2002).”
From Can mild traumatic brain injury alter cognition chronically? A LIMBIC-CENC multicenter study. (2023) · cites this paper as Suhr & Gunstad, 2002
Cites
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BELANGER, H. G., CURTISS, G., DEMERY, J. A., LEBOWITZ, B. K., & VANDERPLOEG, R. D. (2005) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617705050277 · Cited by 715 · see citing works
“Other potential moderators include “diagnosis threat” (Suhr & Gunstad, 2002) and psychiatric variables (Levin et al., 2001).”
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“Diagnosis Threat: This term, proposed by Suhr and Gunstad [88], was adapted from the social psychological concept of stereotype threat [85].”
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“…effect (Hahn, 1997), (b) expectation as etiology (Ferguson, Mittenberg, Barone, & Schneider, 1999; Gunstad & Suhr, 2001; Mittenberg et al., 1992), (c) diagnosis threat (Suhr & Gunstad, 2002, 2005) and, of particular interest to this study, (d) the ‘‘good old days’’ bias (Gunstad & Suhr, 2001).”
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“The present results support the basic finding from Suhr and Gunstad (2002) that expectations regarding diagnosis can influence neuropsychological test performance.”
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“Therefore, our findings may not generalize to examinees with known neuropsychiatric condition or even healthy individuals assessed in a clinical context (i.e. under an implicit diagnosis threat; Suhr & Gunstad, 2002).”
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“Moreover, in their “diagnosis threat” investigations, Suhr and Gunstad ( 2002 ) report data yielding a mean effect size of −0.”
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“Germane to this issue are also the well-documented expectancy effects that occur when people define themselves as belonging to a diagnostic group that is known to perform poorly (i.e., “diagnosis threat”; see Suhr & Gunstad, 2002).”
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“Suhr and Gunstad (2002, 2005) described the results of two studies of undergraduates in which simply calling attention to a history of concussion and the possibility of lingering cognitive symptoms resulted in significantly reduced performance in several areas of neuropsychological function.”
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“Athletes may also be subject to diagnosis threat, or the phenomenon whereby individuals experience greater or more persistent symptoms due to their expectations about that condition (Suhr & Gunstad, 2002).”
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“Finally, as with most MTBI studies, a number of factors not controlled for could have affected the results, among them the effects of somatic syndrome disorder, attention seeking, and diagnosis threat.(48) We have, however, no reason to believe that these effects were particularly pronounced in our study.”
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Misconceptions and Misattributions About Traumatic Brain Injury: An Integrated Conceptual Framework
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“A related concept is that of diagnosis threat, put forth by Suhr and Gunstad [56,57] and replicated by Iverson et al [55] and Ozen and Fernandes [58].”
BackgroundIdentifying Exaggeration and Malingering
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“Finally, Suhr and Gunstad [35,36] present the concept of “diagnosis threat” as a non-neurological contribution to cognitive test performance.”
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“Good old days bias Sources: Gunstad & Suhr 2001 [41]; Iverson et al. 2010 [51]; Lange et al. 2010 [52]; Yang et al. 2014 [59]; Silverberg et al. 2015 [53] Definition: Closely related to expectation as etiology.”
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“We applied a more conservative threshold than Suhr and Gunstad (2002), who considered performance inferior to 1 SD below the mean of the normative data to be pathological.”
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“In two studies by Suhr and Gunstad [24, 25], brain-injured, but otherwise highly functioning university students received either a neutral or a test instruction stating that neuropsychological impairment was common in individuals with a sport brain injury history.”
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“2011; Suhr & Gunstad, 2002), in that some Veterans with mTBI may have performed worse due to negative expectations associated with their injuries.”
BackgroundGender Stereotype Susceptibility
Pavlova, M. A., Weber, S. C., Simoes, E., & Sokolov, A. N. (2014) · PLoS ONE · doi:10.1371/journal.pone.0114802 · Cited by 46 · see citing works
“This may happen presumably due to ‘‘diagnosis threat’’, a kind of stereotype threat [59, 60, 61, 62].”
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“It is also possible that the presence of symptoms or the act of reporting symptoms may result in declines in cognitive performance, as seen in studies of illness‐ or diagnosis‐threat where the belief that one has a condition associated with cognitive impairment may lead to objective performance decrements on cognitive…”
BackgroundSelf- and Informant Ratings of Executive Functioning After Mild Traumatic Brain Injury
Donders, J., Oh, Y. I., & Gable, J. A. (2015) · Journal of Head Trauma Rehabilitation · doi:10.1097/htr.0000000000000120 · Cited by 39 · see citing works
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“Participants were asked to read the following instructions, as originally used by Suhr and Gunstad (2002).”
BackgroundMethodResultInfluentialAn Exploration of Diagnosis Threat and Group Identification Following Concussion Injury
Pavawalla, S., Salazar, R. D., Cimino, C. R., Belanger, H. G., & Vanderploeg, R. D. (2013) · Journal of the International Neuropsychological Society · doi:10.1017/s135561771200135x · Cited by 30 · see citing works
“Suhr and Gunstad (2002) proposed the use of the term ‘‘diagnosis threat’’ (p. 450) to refer to the negative impact on cognitive performance obtained by calling attention to one’s history of concussion and its potential effects on cognition.”
BackgroundResultInfluentialKit, K. A., Mateer, C. A., Tuokko, H. A., & Spencer‐Rodgers, J. (2013) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617713001264 · Cited by 36 · see citing works
“5 standard deviations below the mean, based on published norms for the task), consistent with the methodology used by Suhr and Gunstad (2005), indicated that 43% of heightened threat head-injured participants and 14% of reduced threat head-injured participants exhibited impaired performance.”
MethodPostconcussive Complaints, Cognition, Symptom Attribution and Effort among Veterans
Larson, E., Kondiles, B. R., Starr, C. R., & Zollman, F. (2012) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617712000999 · Cited by 30
“Although groups did not differ in concussion severity, the diagnostic threat group performed worse on tests of memory and reported they put forth less effort on testing (Suhr & Gunstad, 2002).”
BackgroundInfluentialExamining the stress-burnout relationship: the mediating role of negative thoughts
Chang, K.-H., Lu, F. J., Chyi, T., Hsu, Y.-W., Chan, S., & Wang, E. T. W. (2017) · PeerJ · doi:10.7717/peerj.4181 · Cited by 27 · see citing works
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Symon, A., Williams, B., Adelasoye, Q., & Cheyne, H. (2015) · Journal of Advanced Nursing · doi:10.1111/jan.12637 · Cited by 27 · see citing works
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“Fatigue and anxiety may negatively affect neuropsychological testing, as well as the presence of a musculoskeletal injury.(21,22) The subjects mainly spoke 2 languages: Spanish and English.”
BackgroundPhysiological emotional under-arousal in individuals with mild head injury
Baker, J. M., & Good, D. E. (2014) · Brain Injury · doi:10.3109/02699052.2013.857787 · Cited by 25 · see citing works
“It is important to note that participants were not recruited based on a history of head injury, to avoid the impact of diagnosis threat on cognitive performance [76, 77].”
BackgroundSoble, J. R., Spanierman, L. B., & Fitzgerald Smith, J. (2013) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2013.798398 · Cited by 24 · see citing works
“…also can reflect “diagnosis threat” in that past studies also have found that individuals with TBIs may develop negative symptom and outcome expectations that can further perpetuate and maintain perceived postconcussive symptoms (Mittenberg, DiGiulio, Perrin, & Bass, 1992; Suhr & Gunstad, 2002).”
ResultInterdisciplinary rehabilitation of mild TBI and PTSD: A case report
Ryan, P., Lee-Wilk, T., Kok, B. C., & Wilk, J. (2011) · Brain Injury · doi:10.3109/02699052.2011.597044 · Cited by 24 · see citing works
“’s belief that he was suffering from a permanently disabling brain injury, which in turn exacerbated his symptoms [19,32].”
BackgroundBoone, K. (2007) · Archives of Clinical Neuropsychology · doi:10.1016/j.acn.2007.07.005 · Cited by 24
“…Barone, & Schneider, 1999) and “diagnosis threat” (being told by authorities that one is ill and dysfunctional causes a “self-fulfilling prophecy”; Suhr & Gunstad, 2002) no doubt contribute to non-conscious symptom creation/maintenance in settings in which there is external incentive to…”
BackgroundJacobs, W. L., Das, E., & Schagen, S. B. (2016) · Psychology and Health · doi:10.1080/08870446.2016.1244535 · Cited by 26 · see citing works
“AIE findings correspond with studies in the area of mild head injury (MHI) (e.g. Ozen & Fernandes, 2011; Suhr & Gunstad, 2002) that showed increased CPR and diminished performance on neuropsychological tests, when individuals diagnosed with MHI have their attention called to prior head injury.”
ResultCan mild traumatic brain injury alter cognition chronically? A LIMBIC-CENC multicenter study.
Walker, W. C., O'Neil, M. E., Ou, Z., Pogoda, T. K., Belanger, H. G., Scheibel, R. S., Presson, A. P., Miles, S. R., Wilde, E. A., Tate, D. F., et al. (2023) · Neuropsychology · doi:10.1037/neu0000855 · Cited by 22 · see citing works
COVID-19: Impact of Diagnosis Threat and Suggestibility on Subjective Cognitive Complaints
Winter, D., & Braw, Y. (2021) · International Journal of Clinical and Health Psychology · doi:10.1016/j.ijchp.2021.100253 · Cited by 22 · see citing works
“More speci fi cally, ' diagnosis threat ' refers to the impact of negative expectations on complaints regarding cognitive functioning and actual performance in neuropsychological tests (Suhr & Gunstad, 2002).”
Lange, R., Edmed, S., Sullivan, K., French, L., & Cooper, D. B. (2013) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2012.761677 · Cited by 22 · see citing works
“…Lange, Iverson, & Rose, 2011), and a diverse range of social–psychological factors (Davis, 2002; Ferguson, Mittenberg, Barone, & Schneider, 1999; Gunstad & Suhr, 2001, 2004; Hahn, 1997; Hilsabeck, Gouvier, & Bolter, 1998; Mittenberg, DiGiulio, Perrin, & Bass, 1992; Suhr & Gunstad, 2002, 2005).”
Elting, J., Maurits, N., van Weerden, T. V., Spikman, J., Keyser, J. D., & van der Naalt, J. (2008) · Brain Injury · doi:10.1080/02699050802403581 · Cited by 22
“Another important factor may be ‘diagnostic threat’; having attention called to a history of prior brain injury can result in negative expectations, which results in diminished neuropsychological test performance, as was demonstrated in a few recent studies [46, 47].”
Sullivan, K., Edmed, S., & Kempe, C. B. (2014) · The journal of head trauma rehabilitation · doi:10.1097/htr.0b013e31828c708a · Cited by 21 · see citing works
Sullivan, K., Edmed, S., & Cunningham, L. C. (2013) · Brain Injury · doi:10.3109/02699052.2012.698360 · Cited by 21
“…et al. [10] vignette is improved or updated by 86 several of these modifications, or that other vignettes, including those that are not modified 87 * Note: the phrase ‘mild head injury’ was not included in the Suhr and Gunstad (2002) vignette. versions, provide clearer injury information.”
BackgroundThe Psychological Consultative Examination for Social Security Disability
Chafetz, M. (2011) · doi:10.1007/s12207-011-9112-5 · Cited by 21
Tracking the impact of depression in a perspective-taking task
Ferguson, H., & Cane, J. (2017) · Scientific Reports · doi:10.1038/s41598-017-13922-y · Cited by 20 · see citing works
Lamberty, G., Nelson, N. W., & Yamada, T. (2013) · Behavioral sciences & the law · doi:10.1002/bsl.2091 · Cited by 20 · see citing works
Blaine, H., Sullivan, K. A., & Edmed, S. L. (2013) · Journal of Neurotrauma · doi:10.1089/neu.2013.2865 · Cited by 22 · see citing works
“In both studies, the DT group demonstrated significantly worse performance on cognitive tests, compared with those given neutral instructions.(11,21) While Suhr and Gunstad only found changes on tests of general intellect and memory,(11) in a subsequent study they extended these findings to tests of attention, working…”
BackgroundMethodResultInfluentialPlanting a misdiagnosis of Alzheimer's disease in a person's mind
Merckelbach, H., Jelícic, M., & Jonker, C. (2012) · Acta Neuropsychiatrica · doi:10.1111/j.1601-5215.2011.00586.x · Cited by 19
The relationship between concussion and alcohol consumption among university athletes
Alcock, B., Gallant, C., & Good, D. E. (2018) · Addictive Behaviors Reports · doi:10.1016/j.abrep.2018.02.001 · Cited by 18 · see citing works
Katz, D. I., Cohen, S. I., & ALEXANDER, M. P. (2015) · Handbook of clinical neurology · doi:10.1016/b978-0-444-52892-6.00009-x · Cited by 166 · see citing works
Moritz, S., Spirandelli, K., Happach, I., Lion, D., & Berna, F. (2018) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617718000097 · Cited by 17 · see citing works
“In a study on 36 participants with a history of mild head injury (Suhr & Gunstad, 2002), the stereotype (i.e., diagnosis) threat group performed worse than the neutral group on general intellect and memory, whereas no differences occurred for basic attention or psychomotor speed.”
BackgroundPolich, G. R., Iaccarino, M. A., Kaptchuk, T. J., Morales-Quezada, L., & ZAFONTE, R. D. (2019) · American Journal of Physical Medicine & Rehabilitation · doi:10.1097/phm.0000000000001290 · Cited by 38 · see citing works
A comparison of four embedded validity indices for the RBANS in a memory disorders clinic.
Paulson, D., Horner, M., & Bachman, D. (2015) · Archives of Clinical Neuropsychology · doi:10.1093/arclin/acv009 · Cited by 17 · see citing works
“It should also be considered that participants may be reacting to a diagnosis threat created by receiving a memory disorders clinic referral (Suhr & Gunstad, 2002).”
BackgroundKelly, K., & Erdal, K. J. (2016) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2016.1250870 · Cited by 14 · see citing works
Iverson, G. L., & Lange, R. T. (2010) · Springer eBooks · doi:10.1007/978-0-387-76978-3_24 · Cited by 34 · see citing works
Lange, R. T., Yeh, P., Brickell, T. A., Lippa, S. M., & French, L. M. (2019) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2019.1585518 · Cited by 18 · see citing works
“…2006; Iverson, Brooks, Ashton, & Lange, 2010; Iverson, Lange, Brooks, & Rennison, 2010; Iverson & McCracken, 1997; Lees-Haley & Brown, 1993; Meares et al., 2008; Mickeviciene et al., 2004; Ponsford et al., 2012; Suhr & Gunstad, 2002a, 2002b; Sullivan, Hall, Bartolacci, Sullivan, & Adams, 2002).”
Mild Traumatic Brain Injury in the Occupational Setting
Chang, V. H., Lombard, L. A., & Greher, M. R. (2011) · PM & R : the journal of injury, function, and rehabilitation · doi:10.1016/j.pmrj.2011.08.007 · Cited by 15
Guardabassi, V., & Tomasetto, C. (2018) · International Journal of Obesity · doi:10.1038/s41366-018-0121-2 · Cited by 13 · see citing works
Haran, F. J., Dretsch, M. N., & Bleiberg, J. (2016) · Applied neuropsychology. Adult · doi:10.1080/23279095.2016.1166111 · Cited by 14
“…Groome, Thorn, Potts, & Buchanan, 2015), stress, dehydration (Weber et al., 2013), sleep deficits (McClure, Zuckerman, Kutscher, Gregory, & Solomon, 2014), and fatigue (Suhr & Gunstad, 2002); all of which are associated with the various stages of the deployment cycle (Vasterling et al., 2006).”
Background
- Authors
- Suhr, J. A., & Gunstad, J.
- Affiliations
- Ohio University (US)
- Venue
- Journal of Clinical and Experimental Neuropsychology
- Publisher
- Informa UK Limited
- Published
- 2002-06
- Volume
- 24
- Issue
- 4
- Pages
- 448-457
- ISSN
- 0165-0475 (ISSN-L)
- 1380-3395
- 1744-411X
- OpenAlex
- W2006763036
- Cited by
- 229
- References
- 0
- Citations by year
- 2026: 7 · 2025: 3 · 2024: 5 · 2023: 5 · 2022: 6 · 2021: 17 · 2020: 5 · 2019: 13 · 2018: 13 · 2017: 19 · 2016: 11 · 2015: 18 · 2014: 19 · 2013: 24 · 2012: 16
- FWCI
- 1.27
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Clinical and Experimental Neuropsychology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
- Social Sciences › Psychology › Applied Psychology › Psychological Testing and Assessment
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Cognitive Functions and Memory
- Keywords
- negative expectations, mild traumatic brain injury, neuropsychological test performance, cognitive performance, memory, general intellect, psychomotor speed, attention
- MeSH terms
- Adolescent, Adult, Cognition, Cognition Disorders, Female, Craniocerebral Trauma, Humans, Male, Neuropsychological Tests, Surveys and Questionnaires, Stress, Psychological, Task Performance and Analysis
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