Overshadowing

Earlier this week I had a rare moment of cognitive lucidity and tweeted that sometimes the main role of the psychiatrist is to conclude that the problem isn’t psychiatric.

I had two broad and frequently occurring scenarios from clinical reality in mind.

The first is when the patient’s difficulties are far better conceptualised as temporary interpersonal strife or harmless eccentricities. Staff might not be getting on well with a patient, or might be struggling to figure out why they act the way they do. All that is needed in those cases is not a diagnosis or ‘treatment’ but reassurance and perhaps a few pointers on how to understand them better.

But the second scenario in which concluding that the problem is not psychiatric is even more important – when the problem could well be ‘organic’. In these situations,  it could be lifesaving.

It’s a common story. If someone without a history of mental illness goes to A+E with chest pain, confusion or any other worrying symptom, the list of tests and referrals is often generous and sometimes completely exhaustive. The doctors are keen not to miss that rare disease or that subtle sign of a hidden disaster to come. But if someone with a mental illness turns up at A+E with exactly the same symptoms, the amount of investigations that get done is sometimes the bare minimum, if any at all. The vast majority of doctors I’ve worked with are phenomenally caring, holistic and entirely free of this kind of error, but the times when it does happen are hard to forget.

In fact, as I’ve seen many times, the investigation of new symptoms will progress as normal until the very moment when the history of mental health problems is uncovered or when psychiatry show up to help. And then the tests stop.

This potentially deadly phenomenon is the result of what we call ‘diagnostic overshadowing’. Any new symptom that a person with a mental health problem complains of will automatically be put down to the mental health problem. I can understand how it happens. Doctors tend to unconsciously use pattern recognition to figure out which disease or illness a constellation of symptoms is due to, and with such a large confounding factor of a severe mental illness clouding this unconscious process the urge to ascribe the new symptom to the pre-existing problem is logically hard to resist. But sometimes, doctors can stick to this bias despite overwhelming evidence to the contrary. In her book The Centre Cannot Hold Elyn Saks describes turning up to A+E with the worst headache of her life. Despite her friends insisting that this wasn’t part of her usual schizophrenic illness, she was sent home. She was having a subarachnoid haemorrhage.

There are many reasons why the life expectancy of people with severe mental illness is decades shorter than those without. On average they smoke and use drugs more, engage with GPs less, are less able to identify worrying symptoms in themselves, eat less well and do less exercise. But I can’t believe that diagnostic overshadowing is any less significant than any one of those.

But unlike many risk factors for earlier death, diagnostic overshadowing is within the control of health professionals – so how can we fix it?

Firstly,  healthcare professionals in other specialities need greater literacy in mental health. Hopefully, this is happening already. From August there will be a  rise in the amount of psychiatry rotations for newly qualified doctors, so they can learn more about caring for patients with severe mental illness and how to discern what’s mental from ‘organic’. In time, this should reduce the number of calls psychiatrists get from other doctors who don’t know where to start with a patient with a mental health problem as they ‘aren’t trained to deal with this’.

The divisive phrase ‘medically clear’ is no help in this. Before transfer to a psychiatric hospital a patient often has to be declared ‘medically clear’, as if medical and mental are different things, furthering the divide between us. But psychiatrists are doctors who are trained in treating organic disease, and every doctor should be able to do a little psychiatry. We all did placements at medical school. Also, as I’ve discussed before, I don’t think separating psychiatric institutions from other medical instituations either geographically, pragmatically or conceptually is doing the health of our patients any good. It breeds ignorance and therefore error on both sides.

Secondly, we need to listen to patients and their families better (whatever I write about, that always seems to be a conclusion). They need more help to speak up and make their concerns heard, for example from advocacy services or care co-ordinators who actually have the time to attend clinics with them. When they say something isn’t right and isn’t part of their mental illness, we need to believe them and investigate appropriately.

Lastly, liaison psychiatry services are vital in facilitating this and I was glad to see the release of a joint report by a series of medical colleges not long ago recommending a service in every A+E.

I know there are many personal and professional experiences of this topic out there, and I’d be keen to hear them.

 

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About Alex Langford
I am a psychiatry trainee based in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

16 Responses to Overshadowing

  1. This reminds me of when my mother, who had already been diagnosed as manic depressive, was dismissed by her GP when she went to him with a very bad pain in her stomach. He dismissed it by saying it was simply a kink in her intestine which she’d just have to live with. Fifteen years later she had to have gallstones removed which had been building up for many years. It was ‘Mummy’s Pain’ and it sat in the middle of the family, metaphorically speaking, for all those years.

  2. Hope says:

    As someone who lives with both mental and physical illness, I appreciate this post. When I was a teenager, I started having neurological problems that got progressively worse–first dizziness, then passing out, then seizures, then seizures where I’d pass out and stop breathing. I spent over a year trying to get treatment for these issues, but since I had an issue with mental illness and had been in the hospital twice, my GP wrote my symptoms off as psychological attention-seeking because I never had a seizure in his office. (Sorry I can’t schedule those in, doc.) He never did any testing beyond basic blood work. Finally, I had a seizure and stopped breathing at school, and they sent me to a hospital that my doctor wasn’t affiliated with. The first thing they did was a brain scan, and lo and behold, there was an actual problem! Turns out I had a congenital neurovascular defect, and without treatment I probably would’ve had a major stroke or aneurysm. My doctor’s unwillingness to consider a physical problem could’ve cost me my life.

    Now I live with a severe autoimmune disorder, and I end up in the ER more than I’d like. I can see the shift when the nurses or doctors read my chart and find out I have a mental illness. Suddenly they’re not concerned and helpful anymore; suddenly they decide I’m only there seeking drugs and attention. I don’t even bother going to the ER anymore because I know they won’t help me. I just stay home and deal with the excruciating pain the best I can by myself because I know the ER staff aren’t willing to help me. In their mind, crazy people never get sick.

  3. experto crede says:

    Think what you refer to as diagnostic overshadowing infiltrates and leaves a legacy long beyond one off incidents and directly impacts on the mortality rate.

    If you have a disclosed MH condition ( and believe me despite what the NHS states re sharing of info confidentiality doesnt exist in the NHS) differential diagnosis will include MH symptoms.

    My problem is that it often appears right at the top of the list.A dx is also too easily used as an excuse for not following through with standard tests and necessary investigations if the pt is distressed by these or as in many cases frightened or extremely common not communicating in a way staff easily understand.The emphasis being on easily here.

    . It would be good if one day the NHS could actually remember that it is required under the law to make reasonable adjustments for disability and that this goes beyond toilet access.

    The reasons why people dont access the GP or get screened or followed up on is that all NHS systems are almost impossible to navigate There is no OOH GP service and NHS 111 is the most appalling system for those in any form of mental distress ( try mystery shopping that for MH) with or without physical symptoms.

    If you have a MH dx the ambulance service will have a flag and often the police attend. You may have simply fallen down the stairs or have chest pain.You wont nec have any history of resistance. You may know you can be removed on mental capacity grounds.

    Under these circumstances many people wont call even when they have the insight to know they may be seriously ill.I know people who have had MI’s,had post op sepsis, have fallen and broken bones all who knew they were unwell but whose experiences with trying to sort out even routine health issues had damaged their trust in health services.

    The minor injuries units of A&E is rarely full of people with MH diagnoses as they will tend to avoid A&E like the plague.It just feels risky to ask for help sometimes if you know you MH status is going to become the most focuses on issues no matter what problem.

    There is little advocacy support so it’s left to carers and friends to support pts to even the most basic of appts including hospital follow up appointments for physical ailments.It’s an unmanageable burden, the patient with MH problems then gets ‘blamed’ for being difficult and so doesnt go back.

    None of this is rocket science.If you have attended A&E lucid with insight but with a history of MH problems you are acutely aware of how you are being treated. It is blatantly obvious and NHS staff would do well to remember that conversations beyond curtains in public spaces can and are heard.

    If you attend for physical reasons in distress and/or are in the throws of a psychosis the whole experience from beginning to end is traumatic threatening and very frightening for many.So why would this group want to engage,

    There is no parity of esteem and never will be because stigma is more endemic within the NHS than society at large (inner city reference) Clinicians having to acquire MH skills and psych NHS nursing having to acquire skills in physical health needs is laudable but in the latter case laughable.

    They are 2 such separate entities in a reductionist approach to healthcare that the whole model of the NHS would have to be redesigned to get past this.It aint gonna happen Alex – people are scared of MH and that includes you colleagues in the NHS.Just how it is.

    And if I have the capacity to decide whether to attend A&E with chest pain, arterial bleed , pain ,broken bones or deal with it myself then I know which route I and others choose.Which is why we will die younger

  4. SJ says:

    My psychiatrist told me that I was attention seeking, hypochondriac and catastrophising when I kept saying I had sever head pain. It later, 18mths later, transpired that I had a brain tumour. Had surgery later that year and have since also had radiotherapy. If you have a mental illness you can’t possibly have anything else really wrong with you is the opinion of the NHS.

  5. self harmer says:

    I have the opposite experience… which I think is a bit unusual. They tested me for anaemia. Scan, xray, cameras everywhere. Found nothing except that I was more than terrified of tests. Very stressed.

    They didn’t seem to notice the obvious. Scars, plasters, do they see stitching notes from a & e? Once they’d done the tests I expected, it seemed there was no stopping them. They wanted to find the cause of my blood loss.

    My GP has a brain. The expected tests were ok. I cut deep so can bleed a lot. Someone’s got them off my case.

  6. The Armchair Feminist says:

    I actually think there’s a much simpler way of solving this, Alex: don’t let physical health doctors have access to any psychiatric notes. Use a separate system, so that confidentiality can’t be broken.

    • That sounds ideal except in a/e all the notes from a/e are joint and in any case you need to know what medication someone is on- not knowing can prove at worst very dangerous when prescribing for a medical condition.

      • experto crede says:

        The information will leak out however you try and protect confidentiality and remember that all attendances leave a trail.So if you go to A&E there may be A&E notes, Trust notes, MH Trust notes ans a risk assessment from your last attendance.

        In reality there is no legal basis for the NHS to share info – there is legislation forbidding this and indeed you have rights to opt out. It’s only in extreme cases – usually involving criminality and child protection – that this can be breached.

        There is a common law argument but that applies to immediate and clear danger – so the request for info from non MH staff for info is usually in breach of the DPA and Common Law as is the request from MH staff for info from anywhere ( got to have ‘good’ grounds!). However inconvenient Psychs/medics/nurses think this is.

        Staff usually think they have a ‘right’ to access because Trust policy says it’s good practice ( which maybe it is at times).However this doesnt make it legal particularly when a pt/SU has repeatedly and clearly indicated that they do no not want information shared ( as in the red button alert on RiO and other electronic systems refusing consent to share)

        That it is common practice to think all or even some MH history should be shared BECAUSE it’s MH is again an example of no parity of esteem or even basic respect for rights.It is considered a no-no in other sensitive areas such as HIV -few clinicians would argue that they have an automatic right to ‘know’ this information.

        While I understand the very real medication/tx complication issues this is also an issue of autonomy.If I have capacity to make a decision that I do not want the information shared and that is considered a ‘poor’ decision that is still my right.Even if it means I cannot get the same level of treatment that others get as a result.

        But this is the reality of the world of MH in NHS.Rights are few and ignored and much time is spent trying to ‘get around’ them ( from pt perspective) – even if this is sometimes done with best intent.

        But think about it . Would you want your very detailed Risk Assessment that discloses the most personal distressing info within the notes of a general hospital or say with your orthopaedic knee replacement team or gynae team ? When you have NO history of risk to others.

        As a pt as a general rule ( and why the laws are there) I should have the right to choose when , how , why my MH status is disclosed if ever. Because the above scenario is common when information is shared across disciplines and it prevents equality of access and then again will prevent me asking for help.

        Was gonna say can-o worms opened here but starting to feel like big pit of snakes…..

  7. dramallama85 says:

    Several years ago I went to my GP and then A&E complaining of abdominal pain. Despite no tests I was told it was anxiety and provided with the link to an online meditation. When I tried to explain that it wasn’t anxiety I was eventually told that I was attention seeking, and that I mustn’t keep making appointments about the pain.

    I spent several years in sometimes acute pain. I moved to a different NHS area and after becoming very unwell, a GP referred me for tests which revealed I had gallstones and my gallbladder had become infected. I had an operation to remove my gallbladder and it has made a huge difference. But the experience of being left in pain for four years has made me feel that I am very unlikely to be believed about physical symptoms in the future. I worry that some health professionals aren’t able to see past the very negative perception attached to a Borderline Personality Disorder diagnosis.

  8. Onlylearning says:

    I can get behind the feeling that we oughtn’t separate the psych services from the general medical services. The fact that the psychiatric Trust and the acute medical Trust are disparate has been the source of many nightmares over the past few months. But I feel like I’m missing something when you say that the phrase medically fit is a negative one. It’s no different to an SHO in a small rehab hospital with only a few wards pointing out that the patient needs to be well enough that for the most part she/he will be able to care for them as the most senior doctor on hand. I get that it opens that divide of “them” and “us” but how would you choose to phrase it? For the past four months no psychiatrist I’ve met has had more than 2 years of general medical training and we’ve been working in a hospital without even the facilities to take blood cultures, the surgeon or medic does need to appreciate the limitations of the hospital they plan to send someone to. Sorry for wittering, it’s late and I’m tired but had to ask the question. This divide has been a constant bugbear over my psych rotation!

    • Id say it’s the connotation, that ‘the organic medicine has is finished’ rather than ‘they’re stable and well enough to go to a psychiatric hospital’

  9. Impatient_Patient says:

    I think Alex Langord’s typical attitudes are part of the problem here.

    Why keep making a false division between “mental illness” and “organic illness”? Why the Cartesian Dualism? Do you really think that mental illness or mental health are anything other than embodied? Or does mental illness happen out there in the ether? Why the false distinctions between mental illness and organic illness?

    If a patient has pituitary disease, the patient has a problem in their brain. The patient will also experience neuropsychiatric symptoms due to the absence or surplus of hormones. The patient might also have feelings and thoughts about living with pituitary disease which may exacerbate thoughts and feelings that contribute to anxiety or depression. So why treat “organic illness” as some distinct category apart from “mental illness”?

    All diseases and illnesses have a psychological overlay and all diseases and illnesses are embodied.

    If you doctors managed to get yourselves out of the 17th century and developed some insight and were trained better – patients wouldn’t be experiencing problems with diagnostic overshadowing that they currently experience.

    • Hi thanks for the comment. Not really sure you have a grasp of my attitudes towards dualism.

      I’ve written extensively on how nonsensical it is (try my recent post ‘brain/mind divide’) and put organic in quotation marks to show i didn’t believe it myself.

  10. Impatient_Patient says:

    By using the term “organic” in opposition to “psychiatric” or “mental” whether in quotation marks or not, you still serve to reify the division and continue to create an unnecessary boundary.

    For example, take this sentence “But the second scenario in which concluding that the problem is not psychiatric is even more important – when the problem could well be ‘organic’. In these situations, it could be lifesaving.” In this sentence you are creating an unnecessary division between the “psychiatric” and “organic”.

    The same goes for this sentence “and how to discern what’s mental from ‘organic’”.

    In what way is mental not organic and in what way does organic not come with psychological overlay as does every aspect of life? Why the pointless distinction?

    Sticking quotation marks around “organic” and then continuing to use it as a separate category from psychiatric or mental – doesn’t let you off the Dualistic hook.

  11. Thanks, sorry I still disappoint you… In practice we use psychiatric and organic in a pragmatic sense, to delineate the most useful conceptualisation of a problem and therefore the most useful way forward regards care in the system we have…for example, we also talk of whether a patients problems are largely social or medical, though they are of course aspects of the same person. However as I’ve stated many times this runs into problems when people conflate this with dualism, a true separation.

    It’s hardly reification to use quotation marks that highlight that something *isn’t* a genuine natural divide…! :-/

  12. elvis jones says:

    Thanks for this blog Alex. You are a good bloke.

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