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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, 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]
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“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]
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“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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Items 101–200 of 299
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“Mitarbeitende verschiedener Notaufnahmen berichteten in einer qualitativen Studie, dass Beschwerden über körperliche Symptome häufig ohne ausführliche Diagnostik kausal vorliegenden psychiatrischen Diagnosen zugeordnet wurden (Shefer et al. 2014).”
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Salama, R. A. A., Tadross, T. M., Sikandar, I., Ashraf, A., & Khan, A. (2021) · Open Journal of Psychiatry · doi:10.4236/ojpsych.2021.113013 · Cited by 9
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“The reasons underlying observed disparities are multiple (e.g. stigma and diagnostic over-shadowing [Shefer, Henderson, Howard, Murray, & Thornicroft, 2014], reduced access to care) and should be explored in future work (Impara et al., 2022).”
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“For example, while prior studies have shown that uninsured patients are more likely to experience delay in diagnosis, 30,31,37 we found that uninsured patients in our cohort were less likely to experience a delay in diagnosis.”
Garín, D., Mendola, E., Faucherre, Y., Bennar, W., Pittet, T., Cook, S. T., Vivekanantham, H., Jelisejevas, J. J., Cioffi, G. M., Togni, M., et al. (2025) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcaf088 · Cited by 2
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Martinez-Navarro, O., & Martínez‐Martínez, C. (2026) · Journal of Public Health · doi:10.1007/s10389-026-02797-x · Cited by 2
Algoneurodystrophy in a Patient with Major Depressive Disorder
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“There can be stigma and misattribution of physical symptoms due to having a mental illness; diagnostic overshadowing is a form of systemic disparity with negative language and marginalisation around people with SMI [19].”
BackgroundFrom Deinstitutionalization to Deprescribing and Beyond
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“…include the issue of stigma and diagnostic overshadowing, where healthcare professionals attribute physical health symptoms to the SMI diagnosis [36], difficulties engaging in self-management behaviours due to the symptom burden of SMI [37], the high rates of poverty, housing insecurity and…”
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“A classic example of this clinical bias is observed in emergency medicine: Shefer et al. [25] demonstrated that patients with mental disorders frequently have their physical symptoms misinterpreted as psychiatric manifestations, resulting in delays in both diagnosis and treatment.”
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BackgroundApplications of Cognitive Processing Therapy to Post-Injury PTSD: A Case Study
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“…(Happell et al., 2012, 2016), as well as self-stigmatisation (Björk Brämberg et al., 2018), overshadowing (Happell et al., 2016; Jones et al., 2008; Shefer et al., 2014), social isolation (Wang et al., 2017), socioeconomic factors (Ross et al., 2015), initiating healthcare in time…”
InfluentialStigma and Diagnostic Overshadowing in People with Mental Disorder and Substance Addiction
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“Presently, the clinical diagnosis of schizophrenia relies on patient interviews, which depends on subjective self-reporting, and distinguishing its symptoms from other mental illnesses is challenging [44,45].”
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“…and patients with psychiatric diagnoses similarly face a greater risk that physical symptoms will be attributed to their pre existing condition, a phenomenon commonly described as diagnostic overshadowing, resulting in delayed or missed diagnoses (Jones et al. 2008 ; Shefer et al. 2014 ).”
Metadata
- 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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