Diagnostic overshadowing

Diagnostic overshadowing is the attribution of a person’s symptoms of a psychiatric problem, when such symptoms actually suggest a comorbid condition.[1] Diagnostic overshadowing occurs when a healthcare professional assumes that a patient's disability is due to their disability or coexisting mental health condition rather than fully exploring cause of patient's symptoms. Often, once a patient has a confirmed diagnosis, there is a tendency to attribute all new behaviors, or symptoms to the original diagnosis. [2] Diagnostic overshadowing increases the risk of further health complications and delay in accurate treatment.[3] An example of diagnostic overshadowing may be a patient being diagnosed with a psychiatric problem and prescribed medication due to head banging behavior, but the patient actually has communication challenges and can't express pain in mouth due to a dental abscess.

History

The term was first used to describe the under diagnosis of mental illness in people with intellectual or developmental disabilities. [1] In recent years, the term has also been used when physical illnesses are overlooked in people with mental illness.[4]

Causes

Diagnostic overshadowing can occur for several reasons. Diagnostic shadowing most often occurs when a new behaviour develops or previous abnormal behaviors increase. [5] Staff inexperienced with working with people with intellectual disability are also more likely to mistakenly attribute symptoms of a physical illness to a person's intellectual disability. [6] Time pressures of healthcare providers and stigma have been found to be additional causes of diagnostic overshadowing. [7]

Impact

Diagnostic overshadowing can lead inadequate medical treatment for physical health conditions in people with mental illnesses, leading to increased mortality and poorer treatment outcomes. [8] [9] The World Health Organization attributes lower life expectancy in people with intellectual disability or mental illnesses in part to diagnostic overshadowing. [10] In addition to diagnostic overshadowing, people with intellectual disabilities experience barriers to accessing quality health care, increasing the likelihood of developing complex health conditions. People with intellectual disabilities are more likely to be impacted by diabetes, hypertension, obesity and on average die 16 years earlier than their peers without ID. [11]

Diagnostic overshadowing can also lead to delays on treatment or support. When a developmental disorder- such as Autism- is not diagnosed due to diagnostic overshadowing, this can lead to a delay in appropriate support being provided. [12]

Prevention

In the UK, the NHS recommends that local NHS trusts "have effective safeguarding arrangements" to prevent diagnostic overshadowing in people with intellectual disability and autism spectrum disorder. [13] Healthcare providers play a significant role in helping to eliminate the risk of diagnostic overshadowing.

References
  1. Shefer, Guy; Henderson, Claire; Howard, Louise M.; Murray, Joanna; Thornicroft, Graham (2014-11-04). "Diagnostic Overshadowing and Other Challenges Involved in the Diagnostic Process of Patients with Mental Illness Who Present in Emergency Departments with Physical Symptoms – A Qualitative Study". PLOS ONE. 9 (11): e111682. Bibcode:2014PLoSO...9k1682S. doi:10.1371/journal.pone.0111682. ISSN 1932-6203. PMC 4219761. PMID 25369130.
  2. "Diagnostic Overshadowing: See Beyond the Diagnosis". www.intellectualdisability.info. Retrieved 2020-03-28.
  3. Nash, Michael (2013-02-28). "Diagnostic overshadowing: a potential barrier to physical health care for mental health service users". journals.rcni.com. Retrieved 2020-03-28.
  4. S, Jones; L, Howard; G, Thornicroft (2008). "'Diagnostic Overshadowing': Worse Physical Health Care for People With Mental Illness". Acta Psychiatrica Scandinavica. 118 (3): 169–71. doi:10.1111/j.1600-0447.2008.01211.x. PMID 18699951.
  5. Oxford handbook of learning & intellectual disability nursing. Gates, Bob, 1955-, Barr, Owen. (1st ed.). Oxford: Oxford University Press. 2009. ISBN 9780199533220. OCLC 843212345.CS1 maint: others (link)
  6. Kanne, Steve (2018), "Diagnostic Overshadowing", Encyclopedia of Autism Spectrum Disorders, Springer New York, pp. 1–3, doi:10.1007/978-1-4614-6435-8_398-5, ISBN 978-1-4614-6435-8
  7. Shefer, Guy; Henderson, Claire; Howard, Louise M.; Murray, Joanna; Thornicroft, Graham (2014-11-04). "Diagnostic Overshadowing and Other Challenges Involved in the Diagnostic Process of Patients with Mental Illness Who Present in Emergency Departments with Physical Symptoms – A Qualitative Study". PLOS ONE. 9 (11): e111682. Bibcode:2014PLoSO...9k1682S. doi:10.1371/journal.pone.0111682. ISSN 1932-6203. PMC 4219761. PMID 25369130.
  8. Guerin, Bernard (2017-03-16). How to Rethink Mental Illness. doi:10.4324/9781315462615. ISBN 9781315462615.
  9. "New York Times Survey, December 1985". 1987-10-12. doi:10.3886/icpsr08690.v2. Cite journal requires |journal= (help)
  10. "Greater needs, limited access". Bulletin of the World Health Organization. 87 (4): 252–253. 2009-04-01. doi:10.2471/blt.09.030409. ISSN 0042-9686. PMID 19551229.
  11. Hosking, Fay J.; Carey, Iain M.; Shah, Sunil M.; Harris, Tess; DeWilde, Stephen; Beighton, Carole; Cook, Derek G. (2016). "Mortality Among Adults With Intellectual Disability in England: Comparisons With the General Population". American Journal of Public Health. 106 (8): 1483–1490. doi:10.2105/AJPH.2016.303240. ISSN 0090-0036. PMC 4940652. PMID 27310347.
  12. Milen, Mathew T.; Nicholas, David B. (2017-05-16). "Examining transitions from youth to adult services for young persons with autism". Social Work in Health Care. 56 (7): 636–648. doi:10.1080/00981389.2017.1318800. ISSN 0098-1389. PMID 28506122.
  13. Mann, Ian; Sandler, Belinda; Linton, Nick; Kanagaratnam, Prapa (2018). "Drivers of Atrial Fibrillation: Theoretical Considerations and Practical Concerns". Arrhythmia & Electrophysiology Review. 7 (1): 1. doi:10.15420/aer.2017.40.3. ISSN 2050-3369. PMID 29636973.
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