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The Coalition of Behavioral Health Agencies, Inc. Coalition Briefs
An electronic newsletter of the Coalition's Center for Rehabilitation and Recovery

Elizabeth Saenger, PhD, Editor and Writer
No. 108-1, October 15, 2014

The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.

Holistic Care as a Cure for Diagnostic Overshadowing: An Interview with Neil Calman, MD

Diagnostic overshadowing involves missing physical symptoms or problems in a patient with a serious mental illness because of that mental illness. To find out how to avoid this kind of stigma, RECOVERe-works interviewed Neil Calman, MD, a storyteller who captivates readers with vivid portraits of real people to showcase dilemmas in the practice of medicine.

 Dr. Calman’s holistic approach to human beings colors his day job as president, CEO, and co-founder of the Institute for Family Health (IFH). In these roles, he has transformed a family of IFH health centers in New York City and the Hudson Valley of New York State into one of the most respected primary care networks in the region. Dr. Calman also chairs the Department of Family Medicine and Community Health, Icahn School of Medicine, at Mount Sinai.

Why is holistic care a cure for diagnostic overshadowing?

We define people by the problems in the most difficult part of their lives: mental health, developmental disabilities, substance abuse, disease. And because healthcare is not integrated, we cut people up into those categories. With behavioral health patients, we let the mental illness or substance use disorder overshadow other problems (such as physical complaints) and then miss the problems we need to catch. If we approached patients holistically, we would not overlook so much.

What does the Institute for Family Health do to reduce or prevent diagnostic overshadowing?

For us, the way to avoid diagnostic overshadowing is to rework the way we see folks, to see them holistically rather than as the sum of their parts.  We offer integrated services covering mental health, primary care, and dental care. We also have some programs for people with developmental disabilities.

What if someone needs a specialized service, such as drug rehabilitation? 

We refer them for separate substance abuse treatment, but only with professionals who are committed to an integrated model of care, and treat patients as complex people with more than one need. All professionals—whether they are helping patients with mental health problems or high blood pressure—need to treat the patient as a whole person, make more referrals, and take responsibility for follow up.

How might the trend to integrate physical and mental health care affect diagnostic overshadowing?

Integrated care would greatly reduce diagnostic overshadowing—and we need a commitment to such care at the highest level. If health department leadership at a local, state, or national level were committed to integrated care, there would be a trickle-down effect. Many things would change. We would have a unified health department with consistency in regulations, and we would have uniform billing across specialties. We would have much, much more to offer our patients

The key is to talk about a model of integrated care that would cure diagnostic overshadowing and other problems.

Diagnostic Overshadowing: Stigma in Action?

Michael Nash, DProf

Stigmatizing people with mental illness is a problem in healthcare due to diagnostic overshadowing—a phenomenon which occurs when the physical symptoms of people with a mental or intellectual disability are ascribed to that disability. This error can have implications for the physical health outcomes of patients with mental health problems.

Take John as an example. John has schizophrenia. He smokes forty cigarettes a day, has a poor diet and rarely exercises. He is obese and takes antipsychotic medication regularly. His mental state fluctuates, but is described as “stable.”

One day John reports that lately he hasn’t been feeling well; he talks of discomfort in his abdomen and a feeling as if “something is growing inside my stomach.” John’s health worker listens to his reports and after a brief chat notices that John appears less anxious. He documents that John appears to be experiencing distressing delusions, and that his antipsychotic medication may need to be increased to help resolve them.

In this scenario, the health worker’s diagnosis, a possible relapse in mental state, seems like a rush to judgment because it disregards key information that could offer an alternative diagnosis. John smokes, his diet is poor, and he doesn’t exercise. These are key risk factors for colon cancer.

The test of diagnostic overshadowing is this: if John did not have schizophrenia, would his symptoms have been dealt with differently?

Why does diagnostic overshadowing occur?

Nobel laureate Daniel Kahneman and his research partner, Amos Tversky, theorize our reasoning processes stem from System 1 and System 2 thinking. System 1 refers to our intuitive system, which is typically fast, automatic, and effortless, while system 2 refers to reasoning that is slower, conscious, and deliberate.  

Stigma may seduce us into System 1 thinking when a mental health consumer reports physical symptoms. This is especially true when mental illness is salient, since, as Kahneman and Tversky discovered, salience is one of several shortcuts people often use when they think. Salience makes us more likely to overrate the importance, and relevance, of more prominent variables, such as schizophrenia.

Consequently, and ironically, the training mental healthcare professionals receive may exacerbate diagnostic overshadowing. That is because while training can make professionals more aware of stigma, it also makes mental illness more salient. That salience facilitates shortcuts in thinking that lead professionals to overrate the relevance of mental illness as a causal variable, and ascribe symptoms to it.

Another factor contributing to diagnostic overshadowing is the way ideas get lost in translation in mental health. For example, vague symptom reports (“something growing inside me”) are construed as delusional ideas–even in the presence of known risk factors. In contrast, in physical health settings, professionals can paraphrase lay terms for symptoms into medical jargon that makes them sound specific, concrete, and legitimate.

How can we reduce diagnostic overshadowing? 

  1. Be objective. If symptoms can be explained medically, investigate them, because delays in treatment may lead to complications and poorer outcomes.

  2. Form good therapeutic partnerships based on trust and respect. Know consumers’ health history and risk factors to identify problems early. Involving families can be desirable and pragmatic.

  3. Critically reflect on practices at the individual and organizational level that may be barriers to timely integrated care.

  4. Develop specific intervention guidelines tailored to mental health consumers with physical conditions.

  5. Educate mental health consumers about their physical health so they are empowered, and can be more active in managing complex conditions, such as diabetes. 

Dr. Michael Nash is a Lecturer in Psychiatric Nursing, School of Nursing and Midwifery, Trinity College, Dublin.

For more information, see Test your Knowledge on: Diagnostic Overshadowing.


The opinions expressed in RECOVERe-works do not necessarily reflect the views of the Coalition of Behavioral Health Agencies.

To subscribe or unsubscribe to RECOVERe-works, a free publication of the Center for Rehabilitation and Recovery at the Coalition, please email esaenger@coalitionny.org.



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