Diagnostic Overshadowing — MRCPsych Paper B MCQ

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EasyIntellectual DisabilityDiagnostic OvershadowingMRCPsych Paper B

A 32-year-old man with intellectual disability is normally settled and able to engage with familiar carers. After an appendicectomy, he becomes acutely restless, inattentive and confused. Ward staff do not assess for postoperative causes and state that the change is simply due to his intellectual disability. Which clinical error best describes this?

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Correct answer: E — Diagnostic overshadowing

This is diagnostic overshadowing: a new behavioural, cognitive or physical change is incorrectly attributed to the person's intellectual disability rather than investigated as a possible separate condition. The acute postoperative onset, inattention and confusion should prompt assessment for delirium and its underlying causes. Therapeutic nihilism means withholding potentially beneficial treatment because improvement is considered unlikely; it does not describe the attribution error itself. Malingering requires intentional symptom production for external gain, for which there is no evidence. Countertransference concerns the clinician's emotional response to the patient. Overdiagnosis is also incorrect because the problem here is failure to recognise and investigate a new syndrome.

Reference: National Institute for Health and Care Excellence. Care and support of people growing older with learning disabilities (NG96), Terms used: Diagnostic overshadowing. 2018. https://www.nice.org.uk/guidance/NG96/chapter/recommendations