Diagnostic Overshadowing and Psychiatric Diagnoses

The Mad World art exhibition is an aggregation of work by artists, groups, psychologists, psychiatrists, chemists, social workers, and survivors of the psychiatric industry.  It starts with the question: Can you work out who here is diagnosed as Mad ? It then introduces a logic problem created by Raymond Smullyan, one of the finest logicians of our time:… Can you work it out ?

Inspector Cleusau

Inspector Michel of Direction Générale de la Sécurité Extérieure was called over to Britain to investigate eleven insane asylums where it was suspected that something was wrong. In each of these asylums, the only inhabitants were patients and doctors – the doctors constituted the entire staff.
Each inhabitant of each asylum, patient or doctor, was either sane or insane. Moreover, the sane ones were totally sane and a hundred percent accurate in all their beliefs; all true propositions they know to be true and all false propositions they knew to be false.
The insane ones were totally inaccurate in their beliefs; all true propositions they believed to be false and all false propositions they believed to be true. It is to be assumed also that all the inhabitants were always honest – whatever they said, they really believed. In the first asylum Michel visited, he spoke separately to two inhabitants whose last names were Jones and Smith.
“Tell me,” Craig asked Jones, “what do you know about Mr. Smith”
“You should call him Doctor Smith,” replied Jones. “He is a doctor on our staff”
Sometime later, Michel met Smith and asked, “What do you know about Jones ? Is he a patient or a doctor ?”
“He is a patient,” replied Smith.
The inspector mulled over the situation for a while and then realized that there was indeed something wrong with this asylum: either one of the doctors was insane, hence shouldn’t be working there, or, worse still, one of the patients was sane an shouldn’t be there at all.

How did Michel know this ?



The logic problem illustrates how simple things can be immensely confusing, and the world of psychiatry inhabits an area of life that is so complex that the simplistic answers which have been offered to date are not sufficient to be considered effective medicine.

The conversation has been closed down, it has been overshadowed by the authority claimed by the medical world; and through this exclusion of many accounts and perspectives miscarriages of justice have gone on.  This exhibition and archive, inspired by the development of ‘Mad Studies’ as an academic field of inquiry, is a contribution to opening the closed conversations further so that silenced voices might be heard.

Diagnostic Overshadowing and the Stripping of Agency

The academic paper ‘Diagnostic overshadowing: worse physical health care for people with mental illness’ [Acta Psychiatr Scand 2008: 118: 169–171] starts with “It is now well established that people with mental illness die prematurely and have significantly higher medical co-morbidity compared with the general population”.

Diagnostic overshadowing worse physical health care for people with mental illness
Click to download Diagnostic overshadowing worse physical health care for people with mental illness


Harris and Barraclough are cited in the work they did to establish that “All mental disorders have an increased risk of premature death” [Excess mortality of mental disorder. E C Harris, B Barraclough The British Journal of Psychiatry Jul 1998, 173 (1) 11-53; DOI: 10.1192/bjp.173.1.11].


Excess mortality of mental disorder

The fact that there are life altering and life shortening medications which produce conditions such as tardive dyskinesia constitutes significant social justice issues which – should medicine be about healing – must be addressed by any contemporary society seeking to make the claim that it represents the citizens needs and rights. Part of the process which we need to engage is disclosing the voices and stories which are lesser heard of so that they can be included in the conversation that decides the fate of an increasing number of people; those who receive a psychiatric diagnosis.

Silencing The Past; Power and the Production of History

Part of this disclosure is to reveal the silences in history.  Michel-Rolph Trouillot’s thesis in his book ‘Silencing The Past; Power and the Production of History’, is that in the creation of every ‘fact’, there is the creation of a silence. As a historiographer, he examines who gets to make meaning, and what version of history is recognized as respectable.

He makes the point “Effective silencing does not require a conspiracy, not even a political consensus.  It’s roots are structural” [Page 106, Michel-Rolph Trouillot, ‘Silencing The Past: Power and the Production of History’, Beacon Press books, Copyright 1995, ISBN 978-0-8070-4311-0].

Medicine and the authority which institutions create propose many ‘facts’.  It is in the face of these ‘facts’, many voices fall into silences.  The labels which psychiatry has created are proposed as ‘facts’ and are carried forward in the actions of people who identify with the noble ideal of medicine.  The labels of psychiatry carry all the power of an institution and define how people are engaged with – how people are listened to.  A term has been coined ‘diagnostic overshadowing’, which describes a process by which physical symptoms are misattributed to mental illness.
This notion has received little attention in the psychiatric literature but mental health service users have reported its widespread occurrence.  People with psychiatric diagnoses are often disbelieved, as in their very roots, the terms of madness propose that an individual is not in touch with a reliable reality.  This ostracises those individual with diagnostic labels from the most basic and fundamental of human rights and dignities – being listened to and appreciated for their perspectives.
The concept of ‘diagnostic overshadowing’ in patients with mental illness is an important yet under-investigated problem. This can have links with how our perception is obscured by prejudices. One study investigated whether clinicians recommendations for cardiac catheterization differed according to the race and gender of the patient, and it features in cultural competence education for medical students [Schulman KA, Berlin JA, Hareless W et al. The effect of race and sex on physicians recommendations for cardiac catheterisation. N Engl J Med 1999; 340 :618–626].
Rather than using vignettes to train and examine the medics, they video-recorded actors portraying patients with particular types of chest pain. The study found strong evidence that African-American women were less likely to be referred for catheterization than white men and the authors concluded that the ethnic group and gender of a patient could independently influence diagnosis and recommendations for interventional treatment.
A different study showed that particular ethnic groups (African-Americans and Latinos) were less likely to be referred to hospital or to have investigative or treatment procedures, after controlling for diagnosis, severity of illness and access to care [Ashton CM, Haidet P, Paterniti DA et al. Racial and ethnic disparities in the use of health services: bias, preferences or poor communication. J Intern Med 2003; 18 :146–152].
The study examined the different possible influences on the outcomes in looking for bias, preferences, or poor communication. They concluded that during each encounter, the doctor needs to provide openings and prompts to help the patient do 4 specific things:

  1. provide a health narrative
  2. ask questions
  3. express concerns
  4. be assertive

In the psychiatric context, the voice and agency of the individual with the label is stripped and recognition that the individual knows their own health and a realistic perception is undermined by the medical model.
Asking questions is often regarded as manipulative behaviour when coming from the wrong side of a power differential.  Expressing concerns is often taken as impertinence, and being assertive in the face of a power differential can be regarded as aggression or ‘challenging behaviour’.  These are examples of how these medicalized situations can play out.
When we are dealing with the hard question of who to listen to, and what to value, it is vital and important to include a differential diagnostic which takes in a holistic picture of the situation that the individual is tied to – for example, do they have a psychologically abusive partner or family.
All too often, women have been denigrated as hysterical when expressing valid problems, ethnic minorities have been psychiatrically labelled because of cultural expressions which the medic does not relate to, and individuals expressing different gender-sexual norms are medically diagnosed as the physician perceives what they encounter to be adverse to their world view.


Raymond Smullyan’s Solution

We will prove that either Jones or Smith (we do not know which) must be either an insane doctor or a sane patient (but again we don’t know which).
Jones is either sane or insane. Suppose he is sane. Then his belief is correct; hence Smith really is a doctor. If Smith is insane, then he is an insane doctor. If Smith is sane, then his belief is correct, which means that Jones is a patient and hence a sane patient (since we are assuming Jones to be sane). This proves that if Jones is sane, then either he is a sane patient or Smith is an insane doctor.
Suppose Jones is insane. Then his belief is wrong, which makes Smith a patient. If Smith is sane, then he is a sane patient. If Smith is insane, then his belief is wrong, which makes Jones a doctor, hence an insane doctor. This proves that if Jones is insane, then either he is an insane doctor or Smith is a sane patient.

To summarize, if Jones is sane, then either he is a sane patient or Smith is an insane doctor. If Jones is insane, then either he is an insane doctor or Smith is a sane patient.

There are large numbers of critical factors to take into consideration as we collectively evaluate the complexities of ‘madness’; it is clear that it is not just an individual thing, but a socially constructed issue and one which relates to our society at large. Criticism of the simplistic approaches which undervalue and misrecognise the accounts which people give of their own experience must be our starting point on the road to a deeper understanding of the phenomena involved.

Criticism is at the very heart of science, and if medicine strays from this path, of inviting critique and embracing the findings, it is lost. Many feel that psychiatry has already strayed from this path, and this series of articles in the Mad World archive will examine this.

by Alex Dunedin