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“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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“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
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Items 101–194 of 194
Examination of the Role of Expectancies on Task Performance in College Students Concerned about ADHD
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“For example, previous studies have shown that college students who were cued to their mild head injury history performed worse on cognitive tasks compared with students who received neutral instructions (Suhr & Gunstad, 2002, 2005).”
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“…language of insurance reimbursement policies, often places the focus on symptoms rather than on persons, and also creates negative expectations and beliefs among the individuals concerned that can have negative effects on their cognition and behavior (Schwarz et al., 2016; Suhr & Gunstad, 2002).”
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“It is also possible that study advertising materials could have influenced participants’ responses by activating negative stereotypes about the injury, as is sometimes demonstrated on neurocognitive testing in the diagnosis threat literature (e.g., Suhr & Gunstad, 2002).”
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“…social psychological factors may be shaped by the terminology that clinicians use to describe the injury: diagnosis threat (Ozen & Fernandes, 2011; Suhr & Gunstad, 2002; Suhr & Gunstad, 2005); iatrogenesis, including inadvertently contributing to a worsening of symptoms via patient information…”
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“To avoid the possibility of diagnosis threat (see Suhr & Gunstad, 2002) participants were not explicitly informed of the researchers’ interest in head injury status.”
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“Drawing attention to a person’s history of concussion can increase cognitive complaints (Ozen & Fernandes, 2010) and even adversely affect cognitive performance (Ozen & Fernandes, 2010; Pavawalla, Salazar, Cimino, Belanger, & Vanderploeg, 2013; Suhr & Gunstad, 2002).”
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“Moreover, previous studies mostly employed specific neuropsychological measurement tools such as the Wisconsin Card Sorting Test to assess cognitive function [17], but were limited by subjective judgments and the expectation effect; it has been proved that when individuals with mild head injury are informed of this, t…”
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“Recent work by Suhr and Gunstad (2002, 2004) on “diagnosis threat,” supports iatrogenesis as a mechanism in promoting persistent post-concussion syndrome.”
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InfluentialSchwarz, K. A., Pfister, R., & Büchel, C. (2017) · Psychology Health & Medicine · doi:10.1080/13548506.2017.1332375 · Cited by 8
“A similar procedure was employed by previous studies on patients with mild head injury (Suhr & Gunstad, 2002, 2005).”
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Behavioral and Cognitive Aspects of Concussion
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“…mTBI, including depression, anxiety, and personality variables such as negative affect and neuroticism (Clarke, genat, & Anderson, 2012; gunstad & Suhr, 2001; hoge et al., 2008; Iverson, 2005; Lange, Iverson, & Rose, 2011; Lees-haley & Brown, 1993; Meares et al., 2011; Suhr & gunstad, 2002, 2005).”
BackgroundResultSelf-citationAssessing, Documenting, and Accommodating ADHD in College Students
Nelson, J. M., Lovett, B. J., & Lindstrom, W. (2015) · doi:10.1521/adhd.2015.23.6.7 · Cited by 7
Informational literature influences symptom expression following mild head injury: An analog study
Waldron-Perrine, B., Tree, H. A., Spencer, R. J., Suhr, J., & Bieliauskas, L. (2015) · Brain Injury · doi:10.3109/02699052.2015.1004742 · Cited by 7
“of diagnosis threat in clinical samples [1, 10, 13] and those providing information should be careful that there is”
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“Each of these measures have strong psychometric properties (Beck et al., 1988; Blevins et al., 2015; Rush et al., 1996) and have been used previously in mTBI populations (Levin et al., 2021; Stillman et al., 2019; Suhr & Gunstad, 2002).”
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“It has been suggested that providing information results in negative patient expectations and may hamper recovery (Mittenberg et al., 1992; Suhr & Gunstad, 2002; Whittaker et al., 2007).”
BackgroundInterprofessional Collaborative Management of Postconcussion Cognitive Symptoms
Mashima, P. A., Perrine, B. W., MacLennan, D., Sohlberg, M. M., Perla, L. Y., & Eapen, B. C. (2021) · American Journal of Speech-Language Pathology · doi:10.1044/2021_ajslp-20-00313 · Cited by 15
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“However, to avoid the potential influence of diagnosis threat (see Suhr & Gunstad, 2002), participants were not made aware of the researchers’ interest in head injury status andwere told that the focus of the study was to investigate the relationship between physiology, personality, and affect.”
BackgroundPerceptions of the cognitive effects of cannabis use: A survey of neuropsychologists’ beliefs
Hirst, R. B., Watson, J., Rosen, A. S., & Quittner, Z. (2018) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2018.1503644 · Cited by 6
“It is well known that examinee expectations of their own abilities affect cognitive performance on testing (e.g., diagnosis threat; Suhr & Gunstad, 2002), yet research also supports the impact of examiner expectancy effects on cognitive performance.”
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Fresson, M., Dardenne, B., Geurten, M., & Meulemans, T. (2017) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2017.1280450 · Cited by 6
“In the neuropsychological domain, Suhr and Gunstad (2002) showed that students with mTBI exhibited a decline in cognitive performance (stereotype assimilation effect) when reminded of their history of mTBI before they undertook the neuropsychological assessment.”
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Makale, M., Nybo, C., Keifer, J., Blum, K., Dennen, C. A., Baron, D. A., Sunder, K. R., Elman, I., Makale, M. R., Thanos, P. K., et al. (2023) · Brain Sciences · doi:10.3390/brainsci13081179 · Cited by 6
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Caughie, C. A., Kronenberger, O. R., Cobb, J., Margaris, H., McFarland, C. W., & Hall, S. (2022) · Aging Neuropsychology and Cognition · doi:10.1080/13825585.2022.2068498 · Cited by 5
“Literature suggests that negative expectations in and of themselves may decrease performance and increase threat salience (Suhr & Gunstad, 2002).”
BackgroundMethodHow Negative Is Negative Information
Simoes, E., Sokolov, A. N., Hahn, M., Fallgatter, A., Brucker, S., Wallwiener, D., & Pavlova, M. (2021) · Frontiers in Neuroscience · doi:10.3389/fnins.2021.742576 · Cited by 5
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Injury Severity and Depressive Symptoms in a Post-acute Brain Injury Rehabilitation Sample
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Attention Deficit/Hyperactivity Disorder: Diagnosis and Stereotypy
Justman, S. (2015) · Ethical Human Psychology and Psychiatry · doi:10.1891/1559-4343.17.2.135 · Cited by 5
“As a result of what’s called diagnosis threat, people whose attention is called to cognitive losses supposedly associated with mild head injury perform worse on various tests than people with the same history not cued to do poorly (Suhr & Gunstad, 2002).”
BackgroundExecutive Dysfunction After Traumatic Brain Injury
García-Barrera, M. A., Agate, F. T., Wong, R. E., Smart, C. M., & Karr, J. E. (2019) · Springer eBooks · doi:10.1007/978-3-030-25077-5_5 · Cited by 5
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“This exposure to information likely influences the Veteran’s expectations for his or her own experience with symptom recovery, and prior research indicates that these expectations could affect symptom expression and alter the Veteran’s interpretation of his or her subjective experience and behavior [3].”
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Effects of Media Sensationalization on Cognitive Performance and Post Concussive Symptoms
Bussell, C. A., & Gavett, B. E. (2018) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617718000760 · Cited by 6
Diagnosing PTSD: Lessons From Neuropsychology
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“This phenomenon is also seen in actual performance on neurocognitive tests and has been called “diagnosis threat” (Suhr & Gunstad, 2002).”
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“Neuropsychological assessments may not always detect impairments; however, patient-reported cognitive inefficiencies, often exacerbated by sleep disorders, anxiety, depression, and pain, are valid concerns [6,7].”
Psychological correlates of the good old days bias in mild traumatic brain injury
Schlehofer, D. L., & Suhr, J. A. (2024) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2024.2426622 · Cited by 5
“Coined by J. A. Suhr and Gunstad (2002), diagnosis threat is the induction of negative expectancies on cognitive performance secondary to believed consequences of neuropsychological illness or injury.”
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“Other factors that need to be considered are the “diagnosis threat” issues with labeling the patient as concussed or brain injured because it may bias the patient’s performance on testing as well as symptom reporting [10].”
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“Regardless of future research, one should always consider de-biasing methods in evaluating one's forensic work product (Sweet & Moulthorp, 1999 ).”
Diagnosing specific learning disorder in adults Part II: bias, base rates, and a path forward
Harrison, A. G., & sparks, R. L. (2026) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2026.2654023 · Cited by 2
“Providing individuals with misleading information about the meaning of common or nonspecific symptoms can lead them to reinterpret otherwise typical experiences as evidence of pathology, thereby altering responses on self-report measures (Privitera et al., 2015; Suhr & Gunstad, 2002).”
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“In fact, many studies show that such incorrect feedback can make students misinterpret their otherwise common, everyday experiences as being evidence of a disability (e.g., see Privitera, Agnello, Walters, & Bender, 2015; Suhr & Gunstad, 2002).”
The Importance of the Morel Emotional Numbing Test Instructions: A Diagnosis Threat Induction Study
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“Moreover, the deleterious impact of diagnosis threat through self-efficacy was powerful enough to lead to more pathological performance, that is, performance significantly below the clinical (pathological) threshold (see also Suhr & Gunstad, 2002, 2005).”
BackgroundAre ADHD Screeners Safe to Use?
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“…Lockhart & Satya-Murti, 2015), factitious disorders (e.g. Chafetz et al., 2020), illness identity/diagnosis threat (e.g. Merckelbach et al., 2019; Suhr & Gunstad, 2002; Suhr & Wei, 2017), sociogenic illness (e.g. Fremer et al., 2024; Frey et al., 2022), cluster B personality disorders (e.g. Hong…”
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“…stereotype threat manipulation, results are clearer: these threats can negatively affect performance on measures of attention, memory, and executive functions (e.g., Fresson et al., 2019; Hess et al., 2009; Pavawalla et al., 2013; Steele & Aronson, 1995; Suhr & Gunstad, 2002; Trontel et al., 2013).”
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“For example, for an individual’s test scores to be influenced by diagnosis threat, the individual must have a strong belief that they are a part of the group being tested (Suhr & Gunstad, 2002, 2005).”
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Montaigne on Medicine: Insights of a 16th-Century Skeptic
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“2008), psychomotor speed (Suhr and Gunstad 2002), attention (Oken et al. 2008; Suhr and Gunstad 2002), and the figural component of the Torrance creativity test (Rozenkrantz et al.”
BackgroundMethodInfluentialNocebo Effects and Mild Traumatic Brain Injury: Legal Implications
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“Across studies, the effect size of concussion diagnosis threat on cognitive performance has ranged from 0.20 to 0.90 (Suhr & Gunstad, 2002, 2005; Pavawalla et al., 2013).”
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Barber, S. J., Menon, M., Shoemaker, K. J., Mather, M., Langbaum, J. B. S., & Karlawish, J. H. (2025) · Aging Neuropsychology and Cognition · doi:10.1080/13825585.2025.2587702
“In diagnosis threat studies, simply reminding individuals of a medical condition they have (e.g., a history of head injury) can lead to poorer performance compared to when the condition is not made salient (Suhr & Gunstad, 2002).”
DiCarlo, G. M., Ernst, W., & Kneavel, M. E. (2022) · Brain Injury · doi:10.1080/02699052.2022.2034953
Persistent Postconcussion Syndrome
DeRight, J. (2021) · Essential Neuropsychology: A Concise Handbook for Adult Practitioners · doi:10.1007/978-3-030-85372-3_34
Victoroff, J. (2019) · Cambridge University Press eBooks · doi:10.1017/9781139696432.009
先崎, 章. (2016) · doi:10.2490/jjrmc.53.298
Threatening Impairment: Assessing the Effects of Diagnosis Threat on Concussion Screening Tests
Hagler, M. A., & Yu, K. (2014) · The European Proceedings of Social & Behavioural Sciences · doi:10.15405/epsbs.2014.05.14
“Suhr and Gunstad (2002) selected participants who reported an extensive history of head injury.”
BackgroundMaeda, T., Otani, N., Katayama, Y., & Yoshino, A. (2022) · Japanese Journal of Neurosurgery · doi:10.7887/jcns.31.146
Farrer, T., & Cook, S. E. (2021) · Advances in neuroethics · doi:10.1007/978-3-030-62073-8_6
Mild Traumatic Brain Injury, Dementia, and Exercise: Increasing White Matter Integrity in the Brain
Saleemi, S. (2016) · doi:10.25071/ryr.v3i0.40406
“The effects of negative expectations on cognitive performance in head injury, known as diagnosis threats, and development disorders should both be taken into consideration during the diagnosis of mild traumatic brain disorder (Suhr & Gunstad, 2002).”
BackgroundDSM and the Shaping of Depression
Justman, S. (2015) · Palgrave Macmillan US eBooks · doi:10.1057/9781137523297_1
Assessing Psychological Injuries and Malingering: PTSD and Evaluee Considerations
Young, G. C. (2013) · International library of ethics, law, and the new medicine/The international library of ethics, law, and the new medicine · doi:10.1007/978-94-007-7899-3_13
Joanisse, M. (2012) · doi:10.20381/ruor-5657
“…instructions (e.g., mettre l'accent sur la blessure de l'individu et de l'impact éventuel sur la cognition) peuvent modifier la performance des individus ayant été victime d‘un traumatisme crânien léger (Suhr & Gunstad, 2002, voir aussi Kit, Tuokko, & Mateer, 2008 pour une revue de littérature).”
Background
Metadata
- 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 › 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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