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Diagnostic Overshadowing — MRCPsych Paper B MCQ

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ModerateIntellectual DisabilityDiagnostic OvershadowingMRCPsych Paper B

A 35-year-old man with moderate intellectual disability and epilepsy develops increased aggression, self-injury and social withdrawal over 3 months. These behaviours represent a clear change from his usual functioning. His carbamazepine concentration is within the therapeutic range. Which clinician response would most clearly represent diagnostic overshadowing?

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Correct answer: A — Attributing the deterioration to his intellectual disability without assessing possible mental, physical, medication-related or environmental causes

Explanation lettering: E = shown as C · C = shown as D · D = shown as E

Diagnostic overshadowing occurs when new symptoms or behavioural changes are attributed to a person’s intellectual disability, preventing recognition of a coexisting mental or physical health problem. Therefore, **A** is correct. The clear deterioration from baseline—including withdrawal, aggression and self-injury—requires a biopsychosocial assessment covering mental illness, pain or other physical disease, medication effects, communication difficulties and environmental change. A therapeutic carbamazepine concentration does not remove the need for this assessment. Option B describes premature psychiatric attribution rather than diagnostic overshadowing. Options C and D are appropriate components of assessment, while E correctly recognises that these behaviours are nonspecific expressions of distress and are not diagnoses in themselves.

Reference: National Institute for Health and Care Excellence. NG54: Mental health problems in people with learning disabilities: prevention, assessment and management, Context and recommendations 1.6.1 and 1.7.2–1.7.4. 2016; last reviewed 30 July 2024. https://www.nice.org.uk/guidance/ng54/chapter/context