ReviewThe negative Hawthorne effect: Explaining pain overexpression
Section snippets
Conformism as a source of negative Hawthorne effects
The positive Hawthorne effect results in the subject trying to satisfy the observer's expectation of a good outcome. In the seminal experiment [1], manufacturing employees at Hawthorne Works demonstrated increased productivity during an inspection intended to determine whether improved lighting would benefit productivity. The observers noticed that the increase in productivity persisted after the end of the observation period, when the lighting was brought down to its previous level unbeknownst
Pushing for faster management as a reason for negative Hawthorne effects
Pain overexpression due to more or less conscious mechanisms may occur when competition for access to care leads patients to fear they will not be considered as priorities. For instance, understaffing in emergency departments or extended-stay facilities prompt patient to exaggerate the expression of their pain. This mechanism may operate also in pain control centers, which often have long waiting times.
A desire to meet activity criteria as a source for negative Hawthorne effects
In everyday practice, gaining access to certain new medications is theoretically dependent on meeting criteria for a minimum level of disease activity. For instance, TNFα antagonist therapy for spondyloarthritis is indicated only if the BASDAI is above 4/10 [19]. Patients who are aware of these activity criteria may exaggerate their reports of pain to gain access to the drug.
Publicity for a new therapeutic method may lead patients to believe that switching from their current treatment to the
Concern about not being taken seriously as a source of negative Hawthorne effects
Patients may exaggerate the expression of their pain if they fear that their healthcare providers, co-workers, and/or family may underestimate their suffering. A trivial example is the dramatic behavior of soccer players injured on the field, which is designed to increase the referee's evaluation of the severity of the foul. Such behavior is not seen in rugby matches, during which the often-rougher physical contact is not punished in the same way.
A quest for secondary benefits as a source of negative Hawthorne effects
Patients may exaggerate their complaints to obtain compensation for a work-related injury or to perpetuate a situation they feel is advantageous to them, for instance if they are seeking financial reparation or disability status, a sick leave extension, or the granting of social benefits that depend on being scored above a severity cutoff. This type of negative Hawthorne effect is known as malingering, which is intermediate between simulation and accident neurosis [22].
Frustration with the evaluator as a source of negative Hawthorne effects
Patients who are frustrated about not achieving the expected level of relief may exaggerate their complaints to emphasize the inadequacy of their management, even when they have received the best care possible. This behavior may be encouraged by the satisfaction questionnaires handed to patients at discharge, which may lead patients to behave as litigious consumers or to adopt a passive-aggressive behavior. Similar effects may be produced by polemical statements likening healthcare
Interference between the evaluation and various emotions as a source of negative Hawthorne effects
Various emotions may increase the level of pain expression. Anxiety is among them. Patients may fear an increase in pain intensity and a worsening of pain-related limitations that would make them unable to carry out their everyday activities. In this situation, adding an anxiolytic agent may be at least as effective as an analgesic and may also prevent analgesic misuse [24]. Reassurance by the healthcare providers should remain the best means of avoiding anxiety-induced exacerbations in pain
Repeated evaluations as a source of negative Hawthorne effects
Despite the use and misuse of analgesics induced by campaigns to promote pain control, first in the US then elsewhere, the mean pain intensity in the treated population does not seem diminished. Thus, three-quarters of patients using opioids reported persistent severe pain [31]. This finding is further confirmation that analgesics are less effective than believed by the general public and a substantial proportion of healthcare professionals. This misguided optimism can be ascribed in part to
Conclusion
The possibility that negative Hawthorne effects can be induced indicates that:
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patient evaluation is not a neutral act, as repeated evaluations may alter the results;
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suggestion can affect not only the experience of symptoms (placebo effect), but also their expression (positive Hawthorne effect, which should be called into play [39], and negative Hawthorne effects, which should be countered); and;
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negative Hawthorne effects may impair coping [33].
Some of the improvements documented during clinical
Disclosure of interest
The authors declare that they have no competing interest.
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