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
Open accessAbstract
We conducted a qualitative study in the Emergency Departments (EDs) of four hospitals in order to investigate the perceived scope and causes of 'diagnostic overshadowing'--the misattribution of physical symptoms to mental illness--and other challenges involved in the diagnostic process of people with mental illness who present in EDs with physical symptoms. Eighteen doctors and twenty-one nurses working in EDs and psychiatric liaisons teams in four general hospitals in the UK were interviewed. Interviewees were asked about cases in which mental illness interfered with diagnosis of physical problems and about other aspects of the diagnostic process. Interviews were transcribed and analysed thematically. Interviewees reported various scenarios in which mental illness or factors related to it led to misdiagnosis or delayed treatment with various degrees of seriousness. Direct factors which may lead to misattribution in this regard are complex presentations or aspects related to poor communication or challenging behaviour of the patient. Background factors are the crowded nature of the ED environment, time pressures and targets and stigmatising attitudes held by a minority of staff. The existence of psychiatric liaison team covering the ED twenty-four hours a day, seven days a week, can help reduce the risk of misdiagnosis of people with mental illness who present with physical symptoms. However, procedures used by emergency and psychiatric liaison staff require fuller operationalization to reduce disagreement over where responsibilities lie.
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Adherence to assessments that involve invasive examinations or procedures, or unfamiliar treatment settings, can be impaired by various mental conditions.
“adherence to assessments that involve invasive examinations or procedures, such as blood draws and injections, or unfamiliar treatment settings, can be impaired by various mental conditions [69].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [69]
In Results, “Difficulties in communication and challenging behaviour” (page unavailable), the paper reports that some patients with mental illness refused examinations and needle-related procedures such as phlebotomy. “The crowded nature of the ED environment” says a noisy, chaotic emergency department can exacerbate symptoms and make treatment harder, but it does not identify unfamiliarity with a treatment setting as the reason for impaired adherence. (LLM, conf=0.82)
Experimental — accuracy not yet measuredA stressful ED setting can impact patients and ED staff, disturbing communication needed to assess patients' conditions.
“This stressful setting can impact both patients and ED staff, disturbing communication needed to assess patients’ conditions [69].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [69]
Clinicians showing stigma toward clients often leads to lower-quality care and misdiagnoses.
“Clinicians showing stigma toward clients often leads to lower-quality care and misdiagnoses [124].”
From Expressing stigma and inappropriate responses prevents LLMs from safely replacing mental health providers. (2025) · cites this paper as [124]
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- Authors
- Shefer, G., Henderson, C., Howard, L. M., Murray, J., & Thornicroft, G.
- Affiliations
- King's College London (GB)
- Corresponding author
- Shefer, Guy
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2014-11-04
- Volume
- 9
- Issue
- 11
- Pages
- e111682
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC4219761
- OpenAlex
- W1988019453
- Cited by
- 299
- References
- 25
- Citations by year
- 2026: 45 · 2025: 33 · 2024: 29 · 2023: 30 · 2022: 54 · 2021: 22 · 2020: 26 · 2019: 24 · 2018: 12 · 2017: 12 · 2016: 10 · 2015: 2
- FWCI
- 8.26
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Research Portal (King's College London) (submittedVersion)
- Funders
- South London and Maudsley NHS Foundation Trust
- Maudsley Charity
- National Institute for Health and Care Research (RP-PG-0606-1053, NF-SI-0611-10053, NIHR-RP-R3-12-011)
- King's College London
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Keywords
- diagnostic overshadowing, mental illness, somatic symptoms, emergency department, misdiagnosis, delayed diagnosis, employee attitudes, stigma, patient communication, behavioral problems, time pressure, diagnostic process
- MeSH terms
- Attitude of Health Personnel, Mental Disorders, Diagnostic Errors, Emergency Service, Hospital, Female, Humans, Male, Surveys and Questionnaires, Stereotyping
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