The negative Hawthorne effect: Explaining pain overexpression

In medicine, the positive Hawthorne effect is defined as decreased symptom expression due to being observed. This effect occurs in addition to the decrease in symptom experience due to the placebo effect. Symptom overexpression, in contrast, whether related to conscious or to unconscious factors, defines the negative Hawthorne effect, which should be distinguished from the nocebo effect, defined as an increase in symptom experience. For instance, the negative Hawthorne effect can result in patients who seem fully relaxed evaluating their pain intensity at 11 on a 10-point Scale. The negative Hawthorne effect stems from multiple factors including a wish to receive greater consideration or priority management status; concern about failing to meet criteria for receiving a new treatment or being included in a therapeutic trial; conformism related to cultural factors or to circumstance (e.g., avoiding the canceling of a surgical procedure in the event of a last-minute improvement); disease mongering; a desire to be taken seriously by family and friends; a quest for secondary benefits; use of the evaluation to express frustration about being ill or bitterness at receiving a lower level of support; a gap between the expectation of complete relief and the true effectiveness of treatments; and pain exacerbation, with loss of reliability of pain intensity measurements, due to anxiety, guilt, depression, nervosity, catastrophizing, kinesiophobia, or repeated evaluations using methods that involve negative suggestions such as considering the worst pain imaginable. A sequence of a strong negative Hawthorne effect before treatment prescription followed by a strong positive Hawthorne effect after treatment initiation may make a greater contribution than the placebo effect to the improvements produced by treatments for pain.