I work in a general hospital doing mental health clinical work and education. The two roles overlap. A lot.
A significant part of the job is undiagnosing mental illness. It’s not unusual for us to be asked to see somebody who is emotionally overwhelmed or dysregulated. Sometimes this is in the context of mental health problems, often it’s in the context of significant stress. We don’t want to psychiatricise the human condition. Of course you cry when you’re sad. Of course you’re anxious when, like Courtney Barnett in ‘Avant Gardener‘, you’re not that good at breathing in. Of course you’e frustrated when you’re in pain and/or don’t understand what’s going on.
It’s important to validate understandable and proportionate emotions.
It’s equally important to make sure that somebody who has experienced mental health problems previously doesn’t have every presentation to the hospital/outpatient clinic seen through that lens. That’s called “diagnostic overshadowing”. It’s a real problem.
Diagnostic overshadowing is where physical symptoms are overlooked, dismissed or downplayed as a psychiatric/psychosomatic symptom. It must be one of the most dangerous things that happens in hospitals. The President of the Royal Australian & New Zealand College of Psychiatrists, Professor Malcolm Hopwood, said in May 2016, “I sometimes think that the worse thing a person can do for their physical health is to be diagnosed with a mental health disorder.”
It often comes as a shock to people when they find out that those diagnosed with mental illness die between 10 and 25 years younger than the general public. The next shock comes when discovering suicide accounts for only about 14% of premature death. [source: ‘Please believe me, my life depends on it’: Physical health concerns of people diagnosed with mental illness]
It’s a big deal. About 60% of people who experience mental health problems experience chronic physical health problems too. Poor mental health is a major risk factor for poor physical health, and vice versa. [Source: Australia’s mental and physical health tracker 2018]
Diagnostic overshadowing happens outside of hospitals too. In this example, understandable and proportionate human emotions were misinterpreted as psychopathology. The cascade of events that followed makes for a sobering read:
Questions for Reflection
Assuming that you – the person reading this blog post – is a nurse, midwife or other health professional, I have some questions I’d like you to reflect on.
Have I ever witnessed a person’s mental health history influence how their presenting complaint was investigated or treated?
How does my workplace prevent mental health stigmatising and diagnostic overshadowing?
What can I do to support good holistic patient care, without falling into the trap of diagnostic overshadowing?
Happell, B. & Ewart, S. (2016). ‘Please believe me, my life depends on it’: Physical health concerns of people diagnosed with mental illness [online]. Australian Nursing and Midwifery Journal, 23(11), 47.
Harris, B. Duggan, M. Batterham, P. Bartlem, K. Clinton-McHarg, T. Dunbar, J. Fehily, C. Lawrence, D. Morgan, M. Rosenbaum, S. (2018). Australia’s mental health and physical health tracker: Background paper. Australian Health Policy Collaboration issues paper no. 2018-02, Melbourne, AHPC.
Lakeman, R. & Emeleus, M. (2014). Un-diagnosing mental illness in the process of helping. Psychotherapy in Australia, 21(1), 38-45.
Patfield, M. (2011). Undiagnosis: An Important New Role for Psychiatry. Australasian Psychiatry, 19(2), 107–109.
Seriously mentally ill ‘die younger’. (2016, May 10). SBS News. Retrieved from https://www.sbs.com.au/news/seriously-mentally-ill-die-younger
Sincere thanks to Bec (aka @notesforreview on Twitter) for giving permission to share her tweets re mental health stigma and diagnostic overshadowing. Her first-hand account is a powerful cautionary tale.
Paul McNamara, 1st October 2018
Short URL meta4RN.com/shadow