Cited by 229Traumatic Brain Injury ResearchPsychological Testing and AssessmentCognitive Functions and Memory

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“Diagnosis Threat”: The Effect of Negative Expectations on Cognitive Performance in Head Injury

Suhr, Julie A., Gunstad, John·2002·Journal of Clinical and Experimental Neuropsychology

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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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“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.”
BackgroundResultInfluential
Influence of Negative Stereotypes and Beliefs on Neuropsychological Test Performance in a Traumatic Brain Injury Population
Kit, K. A., Mateer, C. A., Tuokko, H. A., & Spencer‐Rodgers, J. (2013) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617713001264 · Cited by 38
“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.”
Method
Postconcussive Complaints, Cognition, Symptom Attribution and Effort among Veterans
Larson, E. B., Kondiles, B. R., Starr, C. R., & Zollman, F. S. (2012) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617712000999 · Cited by 33
“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).”
BackgroundInfluential
Examining 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
Nocebo and the potential harm of ‘high risk’ labelling: a scoping review
Symon, A., Williams, B., Adelasoye, Q. A., & Cheyne, H. (2015) · Journal of Advanced Nursing · doi:10.1111/jan.12637 · Cited by 29
Expectations impact short-term memory through changes in connectivity between attention- and task-related brain regions
Sinke, C., Forkmann, K., Schmidt, K., Wiech, K., & Bingel, U. (2016) · Cortex · doi:10.1016/j.cortex.2016.02.008 · Cited by 26
Effect of Education and Language on Baseline Concussion Screening Tests in Professional Baseball Players
Jones, N. S., Walter, K., Caplinger, R. A., Wright, D., Raasch, W., & Young, C. (2014) · Clinical Journal of Sports Medicine · doi:10.1097/jsm.0000000000000031 · Cited by 25
“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.”
Background
Physiological emotional under-arousal in individuals with mild head injury
Baker, J. M. C., & Good, D. (2013) · Brain Injury · doi:10.3109/02699052.2013.857787 · Cited by 23
“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].”
Background
Neuropsychological functioning of combat veterans with posttraumatic stress disorder and mild traumatic brain injury
Soble, J. R., Spanierman, L. B., & Fitzgerald Smith, J. (2013) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2013.798398 · Cited by 24
“…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).”
Result
Interdisciplinary 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
“’s belief that he was suffering from a permanently disabling brain injury, which in turn exacerbated his symptoms [19,32].”
Background
Commentary on "Cogniform disorder and cogniform condition: proposed diagnoses for excessive cognitive symptoms" by Dean C. Delis and Spencer R. Wetter.
Boone, 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…”
Background
Increased cognitive problem reporting after information about chemotherapy-induced cognitive decline: The moderating role of stigma consciousness
Jacobs, W. L., Das, E., & Schagen, S. B. (2016) · Psychology and Health · doi:10.1080/08870446.2016.1244535 · Cited by 28
“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.”
Result
Can 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
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 26
“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).”
Utility of the Mild Brain Injury Atypical Symptoms Scale to detect symptom exaggeration: An analogue simulation study
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
“…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).”
P300 analysis techniques in cognitive impairment after brain injury: Comparison with neuropsychological and imaging data
Elting, J. W. J., Maurits, N. M., van Weerden, T., Spikman, J. M., Keyser, J. D., & van der Naalt, J. (2008) · Brain Injury · doi:10.1080/02699050802403581 · Cited by 21
“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].”
The Effect of Injury Diagnosis on Illness Perceptions and Expected Postconcussion Syndrome and Posttraumatic Stress Disorder Symptoms
Sullivan, K., Edmed, S., & Kempe, C. B. (2014) · The journal of head trauma rehabilitation · doi:10.1097/htr.0b013e31828c708a · Cited by 21
A comparison of new and existing mild traumatic brain injury vignettes: Recommendations for research into post-concussion syndrome
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.”
Background
The 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. J., & Cane, J. E. (2017) · Scientific Reports · doi:10.1038/s41598-017-13922-y · Cited by 23
Effects and Outcomes in Civilian and Military Traumatic Brain Injury: Similarities, Differences, and Forensic Implications
Lamberty, G. J., Nelson, N. W., & Yamada, T. (2013) · Behavioral Sciences & the Law · doi:10.1002/bsl.2091 · Cited by 23
The Effect of Varied Test Instructions on Neuropsychological Performance following Mild Traumatic Brain Injury: An Investigation of “Diagnosis Threat”
Blaine, H., Sullivan, K. A., & Edmed, S. L. (2013) · Journal of Neurotrauma · doi:10.1089/neu.2013.2865 · Cited by 22
“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…”
BackgroundMethodResultInfluential
Planting 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
Mild traumatic brain injury
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 182
Dysfunction by disclosure? Stereotype threat as a source of secondary neurocognitive malperformance in obsessive-compulsive disorder
Moritz, S., Spirandelli, K., Happach, I., Lion, D., & Berna, F. (2018) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617718000097 · Cited by 17
“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.”
Background
Nocebo Effects in Concussion
Polich, 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 39
A Comparison of Four Embedded Validity Indices for the RBANS in a Memory Disorders Clinic
Paulson, D. L., Horner, M. D., & Bachman, D. (2015) · Archives of Clinical Neuropsychology · doi:10.1093/arclin/acv009 · Cited by 19
“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).”
Background
Diagnostic terminology, athlete status, and history of concussion affect return to play expectations and anticipated symptoms following mild traumatic brain injury
Kelly, K., & Erdal, K. J. (2016) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2016.1250870 · Cited by 14
Post-Concussion Syndrome
Iverson, G. L., & Lange, R. T. (2010) · Springer eBooks · doi:10.1007/978-0-387-76978-3_24 · Cited by 34
Postconcussion symptom reporting is not associated with diffusion tensor imaging findings in the subacute to chronic phase of recovery in military service members following mild traumatic brain injury
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
“…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
Does weight stigma reduce working memory? Evidence of stereotype threat susceptibility in adults with obesity
Guardabassi, V., & Tomasetto, C. (2018) · International Journal of Obesity · doi:10.1038/s41366-018-0121-2 · Cited by 16
Performance on the Defense Automated Neurobehavioral Assessment across controlled environmental conditions
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)
ORCID: Suhr, Julie A.
Gunstad, John
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
DOI: 10.1076/jcen.24.4.448.1039
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 › Clinical Neurology › 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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“Diagnosis Threat”: The Effect of Negative Expectations on Cognitive Performance in Head Injury

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