Trauma-related diagnostic overshadowing

I had never heard the expression “diagnostic overshadowing,” but I now think it’s very important as a reminder to clinicians to be conscientious about primary diagnoses. Wislocki & Zalta (2023) published “Assessing the Existence of Trauma-related Diagnostic Overshadowing in Adult Populations” in Psychological Trauma: Theory, Research, Practice, and Policy.  Here’s the edited abstract and impact statement with key information in bold:

Previous research with youth has shown that clinicians tend to diagnose and treat posttraumatic stress disorder (PTSD) in trauma-exposed clients, even when clinical presentations indicate that PTSD is not the primary diagnosis. The current study sought to examine this trauma-related diagnostic overshadowing bias in adult cases across different types of trauma exposure. Mental health professionals (N = 232) reviewed two vignettes describing an adult seeking treatment for either obsessive-compulsive disorder (OCD) symptoms or substance use disorder (SUD) symptoms (target disorders). Each participant was randomly assigned to one vignette in which one client endorsed exposure to trauma (i.e., sexual trauma or physical trauma) and one vignette in which the client reported no trauma exposure. Following each vignette, participants responded to questions related to the diagnosis and treatment of the client. In both cases, participants were significantly less likely to choose the target diagnosis and treatment and more likely to choose a PTSD diagnosis and trauma treatment when trauma exposure was present in the vignettes. Evidence for the bias was strongest for vignettes that contained sexual trauma compared to vignettes that contained physical trauma. Evidence for the bias was also more consistent in the OCD case compared to the SUD case. Results indicate evidence for the existence of trauma-related diagnostic overshadowing in adult populations, though the strength of this bias may be dependent on aspects of the trauma and overall clinical presentation. More work is needed to understand factors that may impact the presence of this bias.

Findings indicate that clinicians may assign ill-fitting diagnoses and leverage less appropriate treatments when clients present with trauma exposure and unrelated mental health symptomatology. Disclosure of trauma exposure may impact clinical decision making in the diagnosis and treatment of adult populations. 

This work is important in extending findings with youth to adults. It’s also helpful in identifying the relative power of sexual trauma in biasing diagnosis and treatment planning. The design is very clever and the sample large enough to be persuasive. More work is obviously needed but it is a clear cautionary tale for those who diagnose adults.