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Diagnostic Overshadowing in Psychiatric-Somatic Comorbidity: A Case for Structural Testimonial Injustice

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Abstract

People with mental illnesses have higher prevalence and mortality rates with regard to common somatic diseases and causes of death, such as cardio-vascular conditions or cancer. One factor contributing to this excess morbidity and mortality is the sub-standard level of physical healthcare offered to the mentally ill. In particular, they are often subject to diagnostic overshadowing: a tendency to attribute physical symptoms to a pre-existing diagnosis of mental illness. This might be seen as an unfortunate instance of epistemic bad luck, where particular features of a group of patients make a timely and correct diagnosis unlikely. While this can explain some cases of diagnostic overshadowing, I argue that in other cases, epistemic injustice is involved. Analyzing the case of diagnostic overshadowing, I distinguish two kinds of testimonial injustice. For one, there are classic cases of transactional testimonial injustice resulting from prejudices against the mentally ill. In addition, there are cases of structural testimonial injustice resulting from features of health care systems. To overcome diagnostic overshadowing, remedies on the individual as well as structural level are thus needed.

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Notes

  1. The higher discrepancy in life expectancy found by the Scandinavian studies can be explained by their inclusion of substance-abuse disorders.

  2. The contemporary wording of “mental retardation” has been replaced by “intellectual disability” in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) because of its pejorative character and protests by patient advocates (Regier et al., 2013).

  3. Jopp and Keys (2001) also note a phenomenon they call “treatment overshadowing”, in which the patient with an intellectual disability and a concomitant mental disorder gets diagnosed but still not treated for that mental disorder (ibid., 418 f).

  4. Sometimes, the disadvantaged members of marginalized groups create new concepts and understandings of phenomena (for instance, via discourse aimed at consciousness-raising, as was practiced during the 2nd-wave women’s movement). In such cases, these new resources sometimes do not catch on, but are willfully ignored by more dominantly situated knowers (Pohlhaus jr., 2012).

  5. Gosselin also emphasizes that the application of these stereotypes differs depending on the kind of mental disorder at hand; e.g., patients with schizophrenia are feared to be uncontrollably violent, whereas those suffering from depression are considered as weak-willed. For discussions of epistemic injustice in relation to specific mental disorders, cf., e.g., Jackson (2017), Sanati and Kyratsous (2017), Miller Tate (2019).

  6. By contrast, the lack of access to physical health care that often is an effect of the social marginalization of people with mental illnesses could be understood as a structural form of pre-emptive testimonial injustice: the patient does not get the chance to present his symptoms, but this is not the fault of any particular physician.

  7. For instance, a possible symptom of schizophrenia is somatic delusions, where the patient suffers from the mistaken belief of having a terrible disease.

  8. Another possibility would be that these assessments of patient reports are based on an assumption that people with mental illnesses are less likely to have somatic comorbidities. Such an assumption, however, would not provide a generally reliable stereotype either, as it is clearly incorrect (see Sect. 2.1).

  9. Another point mentioned in the interviews (see Sect. 2.2) was that a pre-existing psychiatric diagnosis makes it easier and seemingly more permissible to dismiss a patient quickly and without investing time in lengthy diagnostic procedures (Shefer et al., 2014). This illustrates how prejudice and institutional structures often go hand in hand.

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Acknowledgements

I want to thank Anne-Marie Gagné-Julien, Somogy Varga, and two anonymous reviewers for their valuable remarks on an earlier version of this paper. In addition, I have greatly profited from comments on earlier versions of the paper by the audiences at the 2nd joint MCMP-Hanover Workshop “Philosophy of Science”, the workshop on “Classification in the Era of Personalized Medicine: Perspectives from History, Philosophy and Policy” in Berlin, and the research colloquium at the Center for Science Studies at Aarhus University.

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  1. Department of Philosophy and History of Ideas, School of Culture and Society, Aarhus University, Jens Christian Skous Vej 7, 8000, Aarhus C, Denmark

    Anke Bueter

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Bueter, A. Diagnostic Overshadowing in Psychiatric-Somatic Comorbidity: A Case for Structural Testimonial Injustice. Erkenn 88, 1135–1155 (2023). https://doi.org/10.1007/s10670-021-00396-8

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