Diagnostic Overshadowing
What is Diagnostic Overshadowing?
Diagnostic overshadowing is the misattribution of symptoms of one condition to a co-occurring condition.1,2,3 This may occur due to legitimate concerns that are attributed to physical or mental health symptoms, largely due to implicit cognitive biases resulting in an underestimation or misattribution of symptoms.3 For instance, a prior psychiatric diagnosis can unintentionally limit further medical inquiry, leading providers to interpret health concerns as part of the patient’s disability instead of investigating potential underlying medical causes. When a patient has a known condition, clinicians may approach new symptoms through the lens of that diagnosis. This is known as the anchoring effect, and is one of many cognitive biases that may lead to diagnostic inaccuracies.3 Along with this, include personality traits such as overconfidence and risk aversion, which are associated with diagnostic inaccuracies.3
Why is Diagnostic Overshadowing Important?
It’s important to understand the impacts of diagnostic overshadowing because individuals with mental health conditions experience higher rates of physical illness conditions and mortality.4 Delayed or missed diagnoses associated with diagnostic overshadowing contribute to reduced access to appropriate treatment and shorter life expectancy among individuals with complex health needs.4 Diagnostic overshadowing exemplifies the systemic bias where clinicians may partially overshadow symptoms by attributing them solely to disability or psychiatric characteristics.2,5 There is decreased accuracy in diagnosis which reflects the increased difficulty in assessment and consideration of interplay amongst disability and mental health, indicating a need for increased training and special considerations.5 Furthermore, individuals from marginalized racial and ethnic groups and those with dual diagnoses face higher risk of diagnostic overshadowing, contributing to disparities in diagnosis, treatment, and overall health outcomes.1
Some individuals with intellectual and developmental disabilities or mental health conditions may experience atypical pain perception and expression.6,7 Differences in nociception, the detection of painful stimuli, sensory processing, or emotional awareness, such as alexithymia, can affect how pain is recognized, experienced, or communicated and expressed. 6,8 As a result, individuals with and/or without dual diagnoses may express pain or distress in unexpected ways. For instance, a patient may present with a fractured arm but be unable to verbally communicate the injury or demonstrate typical pain responses. They might understand something is wrong, but struggle to communicate the pain, location of injury, or express typical pain-related injuries that a provider may be accustomed to seeing in a neurotypical patient.