![]() Second, a trainee psychiatrist should consider the possibility of diagnostic overshadowing and its attendant iatrogenic risks. First, it demonstrates the need for a thorough neurological assessment along with maintaining a high index suspicion for organic possibility in every ostensibly atypical psychiatric presentation. The film, therefore, contains numerous lessons. 5 This process is further complicated in the elderly population whose autoimmune conditions may not be considered as differential diagnoses for neuropsychiatric presentations. 4 Furthermore, the access to immunological and laboratory testing is limited, leading to further delays in determination of the diagnosis. 3 In fact, there have been reports of cases of autoimmune encephalitis, which were diagnosed following a negative autoantibody test result (31.4%, according to a few studies), leading to further delays in exact diagnostic identification of the condition. 2 Adequate training to increase the knowledge of the appropriate clinical warning signs can lead to a significant reduction in the time taken to achieve a diagnosis of an autoimmune neuropsychiatric condition. The misattribution of these presentations leads to a significant delay in instituting effective treatment. It is now common knowledge that dramatic psychiatric symptoms can manifest as the early signs of illness in 60% of autoimmune encephalitis cases. The brain biopsy established the diagnosis of anti-NMDA encephalitis that could be treated with plasmapheresis and corticosteroids. The bedside clinical lobar function tests conducted by her brilliant neurologist ultimately established the need for a brain biopsy, an invasive investigation not part of routine practice. Psychiatric diagnosis was considered when there was no apparent investigative finding. Her family faced considerable distress due to an uncertain diagnosis leading to inconsistent and ultimately ineffectual treatment. However, these were disregarded following a lack of clear radiographic and electroencephalographic evidences.Įventually, Cahalan was hospitalised following agitation, disorientation and multiple seizure episodes. Further striking changes appeared with the onset of seizure episodes, which pointed towards a neurological illness. Thus, her presentation was quite polymorphic where symptoms could have been classified as a psychotic or mood disorder. Gradually, these progressed to frank paranoia and unstable mood. Her symptoms included subtle perceptual disturbances, fatigue, depressed mood and apparent withdrawal. ![]() She is the protagonist of the movie which vividly dramatises a presentation characterised by psychotic symptoms with an underlying oft-underdiagnosed autoimmune pathology. 1 The movie Brain on Fire is based on the real life of the New York Post journalist, Susanna Cahalan. There are potentially several underlying reasons for this, including diagnostic challenges in establishing a medical cause for the presenting symptoms, likely lack of expertise in medicine, stigma directed towards mental illness, a protean or polymorphic presentation not immediately relating to an established nosology, lack of a reliable evidence base in the area leading to an inability to correlate with established medical diagnoses as well as biases towards treating surface-level symptoms instead of identifying the underlying causes. Diagnostic overshadowing refers to a phenomenon commonly characterised by a person with pre-existing or recently diagnosed mental illness receiving inadequate attention for symptoms of physical illness, which are then misattributed as manifestations of the mental illness.
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