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Diagnostic overshadowing: self-injurious behaviour as a manifestation of pain in the head and neck


In the healthcare domain, diagnostic overshadowing is a concerning issue involving the erroneous attribution of physical symptoms to a patient's mental health, behavioural intricacies, or pre-existing disabilities. Individuals facing learning and communication challenges are particularly susceptible to this phenomenon, struggling to articulate or comprehend their experienced symptoms. Likewise, patients with autism spectrum disorder can have an escalated risk due to possible challenges in interpreting bodily cues. This article delves into the specialised care required for individuals with learning disabilities and/or autism, highlighting the pervasive risk of diagnostic overshadowing and the potential manifestation of pain as self-injurious behaviour in these patient groups. By underscoring the need to mitigate diagnostic overshadowing within dental practice, we advocate for reasonable adjustments in care delivery and comprehensive education of the dental team. Proficient tools for pain assessment and effective communication are emphasised to collectively improve the healthcare experience for these vulnerable patient cohorts.

Key points

  • This article sheds light on the significant barriers, such as communication and interoception difficulties, that can be faced by dental patients with learning disabilities and/or autism spectrum disorder. These barriers can lead to diagnostic overshadowing and hindering accurate dental or medical assessment and appropriate care.

  • Offers clinical cases to demonstrate the link between self-injury and pain in individuals with learning disabilities or autism spectrum disorder, recognising self-harm as a potential indicator of underlying physical or emotional distress.

  • Provides an overview of useful tools available for communication and the assessment of pain in patients, emphasising their vital role in preventing misdiagnoses. By advocating for education and heightened awareness within dental teams, we aim to ensure optimal care and support for vulnerable patients.

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Authors and Affiliations



Mona Yekezare: case selection, compilation of background research and synthesis of article. Stacey Clough: concept and structure, writing and review of article. Patricia Handley: background research guidance, discussion of cases and review of article.

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Correspondence to Mona Yekezare.

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Yekezare, M., Handley, P. & Clough, S. Diagnostic overshadowing: self-injurious behaviour as a manifestation of pain in the head and neck. Br Dent J 236, 876–880 (2024).

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