Christopher Lawer reports financial support was provided by Anxiety UK. Christopher Lawer reports a relationship with Anxiety UK that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Our research [1] provides the first empirical statement of the scale of medical gaslighting and diagnostic overshadowing in the health care experiences of people with GAD in the UK. More positively, it also reveals high GP and patient awareness of these issues, as well as a desire to address them. But we did not only wish to gauge the level of awareness. We also wanted to surface the demand for innovation of new tools and resources. Our research does so. GPs are clearly expressing a wish to improve their assessment, decision-making and treatment skills for physical health conditions when reported by people with GAD. They seek guidelines and diagnostic aids to better know and incorporate the history, circumstances and self-reporting capabilities of GAD patients when making clinical judgements. Encouragingly, they are also aware of how their own conscious or unconscious biases might inform their approaches and decision-making when interacting with GAD patients.Having similar positive intent, people with GAD are seeking resources to support them too. Pre-appointment aids, physical symptom records, journals and conversation tools would help improve their outcomes in consultations with HCPs, especially GPs. Given the expressed need of both parties for new interactional and diagnostic tools and technologies, the conditions for innovation and their adoption would seem favourable. With concerted effort, it should then be possible to find novel ways to detect physical health conditions at the right time, avoid iatrogenic harm, and improve the health care experiences and outcomes for people living with GAD.Finally, we express three hopes from our research. We hope it raises awareness of the unique challenges faced by people with GAD in their healthcare encounters. We hope it motivates additional research to further understand the causes, forms and consequences of medical gaslighting and diagnostic overshadowing in this patient group. Finally, we hope it drives real impetus for innovation and change in clinical thought and practice when HCPs engage with people living with GAD and other anxiety disorders.

This study quantifies the widespread presence of medical gaslighting and diagnostic overshadowing in people with GAD in the UK.

Interpretation: Medical Gaslighting and Diagnostic Overshadowing of Patients with Generalised Anxiety Disorder in the UK: Evidencing and Addressing the Problem.

Our headline finding is that people with GAD are 2 to 3 times more likely to experience either medical gaslighting or diagnostic overshadowing when reporting their physical health problems to HCPs, when compared to people who do not have GAD. Aware of this, we also found widespread HCP desire to better understand and address this difference and its inequitable outcomes. Around 4 out of 5 of all GPs wish to enact the ideas proposed in the survey (suggestions that were also rated highly by GAD respondents). A majority of GPs acknowledge that when presenting with physical health complaints, people with GAD require particular attention and need more consultation time.Nevertheless there are limitations to what can be done. GPs find it hard to enact and sustain dedicated modes of practice consultations for people with GAD and other anxiety conditions for two reasons. First, limited resources and operational constraints constrain their capacities to adapt the form and extend the time of patient consultations for GAD patients in primary care. Second, bespoke consultations are difficult to plan and undertake because of the challenges of a) stratifying GAD patients prior to their consultation, b) isolating anxiety behaviour and symptoms during a consultation, and c) incorporating non-clinical factors when making a diagnostic assessment.&nbsp;In the final section, we explore the clinical implications and possibilities for addressing MG and DO in the clinical setting.

Analysis: Medical Gaslighting and Diagnostic Overshadowing of Patients with Generalised Anxiety Disorder in the UK: Evidencing and Addressing the Problem.

SURVEY FINDINGSWe present the survey results in two parts, first for people with GAD (“GAD respondents”) and for comparative purposes, people without GAD (“non-GAD respondents”), and second, for GPs in primary care.GAD / non-GAD surveyAll GAD/non-GAD patient respondents were asked if they had ever experienced problems getting professional medical help for a physical health problem they had reported to a HCP, whether directly because of their GAD (GAD patient respondents) or independently of any mental health condition (non-GAD respondents).55.7% (132 of 237) of GAD respondents reported they had never experienced problems getting help for a reported physical health condition because of their GAD, meaning that just over 4 in 10 (44.3% or 105) GAD respondents had experienced problems. This contrasted with all 259 of the non-GAD respondents reporting they had problems getting professional medical help for a physical health condition or disease.For the 44.3% of GAD respondents reporting difficulties getting help, just over half reported experiences of MG as a factor. 53% of this sub-group of GAD patients with problems stated they had not had their symptoms taken seriously by a HCP. &nbsp;51% claimed they have had their symptoms ignored, denied and/or dismissed by one or more HCP. These compared with 15% and 24% for non-GAD respondents for the same reasons respectively, all of whom reported problems obtaining healthcare for physical health conditions.In Figure One, we depict the percentage proportions of (the subset of) GAD respondents reporting different forms of MG compared with non-GAD respondents.<img src="https://science-octopus-publishing-images-prod.s3.eu-west-1.amazonaws.com/clye5zl760001wtwpg9iknywv" alt="Coming soon" title="MG DO Figure 1.jpg">Figure One – Percentage of GAD and non-GAD respondents recording “yes” to eight MG/DO statements (GAD-105 respondents. Non-GAD-259 respondents)Women with GAD in the group reporting problems were especially likely to report MG experiences. 62% of female GAD respondents stated they felt their symptoms were not taken seriously by one or more HCP, compared to 26% of men. Similarly, 61% of female respondents with GAD recorded being ignored, denied, or dismissed by a HCP (compared to 17% of men).Additionally, around 1 in 5 GAD respondents who experienced problems getting help for a reported physical health condition because of their GAD cited experiences of diagnostic overshadowing. 23% stated they had had their symptoms of a physical condition mistaken for their GAD, and 20% stated that a HCP had not been aware that anxiety can be a symptom of an underlying physical condition. Amongst non-GAD respondents, recorded DO was much lower for the same two reasons, at 7% and 3% respectively.1 in 3 GAD respondents who experienced problems reported that their GAD complicated their ability to obtain an accurate diagnosis for a reported physical health condition/disease. This compared to just over 1 in 10 (12%) of non-GAD respondents citing problems obtaining a physical health diagnosis due to a (non-GAD) mental health condition. Of interest is the higher reported incidence of DO in younger age groups. Half of GAD respondents aged 18-24 were more likely to report that GAD complicated their ability to get an accurate diagnosis for a physical health condition/disease, compared with 30% of non-GAD respondents aged 18-24.MG/DO and reported physical health conditions.Respondents were asked to record the physical health conditions where they experienced MG/DO. Of the 105 people in the GAD group reporting difficulties, there were a total of 274 reports for different physical health conditions (a person could record a problem with more than one condition in the survey). Of these 274, the most common conditions reported were as follows:·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Sleep conditions, 35 of 105 respondents reported problems (31.4%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Digestive tract (21/105 – 20%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Ear, nose and throat (16/105 – 15.2%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Gynae (15/105 – 15%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Oral, dental problem (15/105)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; MSK (13/105)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Chronic / neuropathic pain (12/105 – 11.4%)All respondents were asked about the duration and the impact of problems getting medical help for their reported physical health symptoms. People with GAD experienced problems over longer time periods and with more negative impact on their lives. 50% of GAD respondents reporting problems had had difficulties for more than 5 years GAD compared with 18% of non-GAD respondents, and the same group experienced more severe life impacts (42.0%) compared with non-GAD respondents (16.7%).Improvements to prevent MG/DOIn respect of preventing and dealing with MG/DO, GAD respondents reported that the following would be helpful (they were provided with a list of suggestions):·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; More time with HCPs (desired by 67% of GAD respondents compared with 44% of non-GAD respondents)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A means to record/reference what HCPs have told them for use in future appointments with other HCPs (56% / 25%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; More face-to-face appointments with HCPs (56% / 48%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Ability to have medical appointments when symptoms are present (56% / 44%)Finally, GAD respondents suggested the following resources and tools would be helpful in their interactions with HCPs:·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Having a prepared set of questions to ask (45% GAD compared to 22% non-GAD)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Being able to see their medical record (53% / 32%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Help with being calm/composed before appointments (47% / 14%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A helpline for use before or after appointments with medical professionals (32.4% / 16%)GP surveyAlmost all GPs (96%) believe that people with GAD at least occasionally (more so than “rarely” or “never”) experience forms of medical gaslighting or diagnostic overshadowing. 68% of GPs reported this happens very often (24%) or often (44%) for people with GAD. Of particular note, 70% of GP respondents believe that cognitive bias (including unconscious bias) often, very often, or always makes it more challenging for people with GAD to receive a diagnosis and/or obtain access to tests and treatments for their non-GAD conditions.In respect of consequences, more than half of GPs (53%) report that patients with GAD often, very often, or always discontinue seeking care or professional support for physical health concerns because of challenges experienced in primary care settings. More than 9 in 10 GPs (91%) say that patients with GAD at least occasionally discontinue seeking care. Furthermore, 1 in 3 GPs identify that GAD patients often, very often, or always switch to private healthcare due to their experiences. These findings match those from the patient survey. People with GAD reported they are more than twice as likely to seek private care (43%, compared to 19% of people without GAD).&nbsp;Of concern, respondents with GAD are more likely to stop&nbsp;seeking healthcare altogether&nbsp;(39%, compared to 25% of those&nbsp;without GAD).The survey identifies that people with GAD seek private health care for three main reasons: 1) problems with the mode, content and the continuity of HCP consultation, 2) inadequate amount of time spent in consultation, and 3) the absence of diagnosis and support for certain physical health conditions. Results suggest that GPs concur. First, over half of GPs (55%) report that the recent shift in the UK from face-to-face to telephone consultations has negatively impacted patients living with GAD compared to the general population. Second, a majority of GPs (66%) believe they have insufficient time to engage with GAD patients. Female GPs are more likely to cite insufficient time (74%) and the lack of continuity of care (57%) as key challenges compared to their male peers (at 59% and 39% respectively). Third, at least half of GPs report that patients with GAD experience more challenges or delays accessing professional help for certain conditions, in particular ME/Chronic Fatigue Syndrome (55%), sleep and sleep conditions (50%), and chronic and neuropathic pain (50%).As in the patient survey, GPs were asked to evaluate ideas for improving the quality of their engagements and outcomes with GAD patients. Nearly all were rated highly, especially:·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Having a GP with an extended role or specialist interest in mental health within the practice (85% of GPs surveyed)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Patient tools translated into different languages (84%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Extended appointment times for patients with GAD (84%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Increased primary care access to a multi-disciplinary team for patients with GAD (82%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Patient education on anxiety symptoms and their overlap with other health conditions (80%)·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; HCP education on anxiety symptoms and their overlap with other health conditions (80%)Next, we discuss the above summary findings.

Results: Medical Gaslighting and Diagnostic Overshadowing of Patients with Generalised Anxiety Disorder in the UK: Evidencing and Addressing the Problem.

The three forms of medical gaslighting of people with GADFrom a GAD patient perspective, being medically gaslighted occurs when a HCP unjustifiably denies, rejects or downplays the patient’s expressed or reported symptom(s) of a physical health problem. MG may arise in one or more of three forms:1.&nbsp;&nbsp;&nbsp;&nbsp; The GAD patient does have the physical health problem, and their complaint and symptoms are mistaken for or attributed by the HCP to their GAD symptoms, including the patient’s anxiety behaviour exhibited in their interaction.2.&nbsp;&nbsp;&nbsp;&nbsp; The HCP has prior knowledge that the patient has or has had GAD in the past, and this informs their clinical judgment of the presence of, or need to investigate their physical health condition, even if no GAD symptoms are currently expressed or observed in the clinical encounter.3.&nbsp;&nbsp;&nbsp;&nbsp; The person with GAD just believes the HCP’s judgment or decision to be wrong based on their own gut-feeling, knowledge or prior experience.The three forms of diagnostic overshadowing of people with GADUnlike MG, DO is when a GAD patient is given a diagnosis for an expressed or reported physical health condition by a HCP in one of three ways,1.&nbsp;&nbsp;&nbsp;&nbsp; The HCP overshadows a patient’s complaints of a physical health condition by attributing its expressed or observed symptoms to their GAD (similar to the first form above in the MG list). For example, they may attribute palpitations (a common GAD symptom) to someone’s GAD rather than to an actual or potential cardiac problem, and then decide not to investigate that cardiac issue.2.&nbsp;&nbsp;&nbsp;&nbsp; A HCP overshadows a physical health condition by attributing its manifestation in anxiety behaviour and symptoms to a patient’s GAD. For example, they may assign someone’s heightened anxiety to a patient’s existing GAD condition, rather than to their genuine undiagnosed thyroid problem (where anxiety is a symptom).3.&nbsp;&nbsp;&nbsp;&nbsp; Finally, the HCP may newly-diagnose GAD for a patient presenting with anxiety-related symptoms or showing anxiety behaviours instead of diagnosing or agreeing to investigate the reported physical health condition.Design of survey instrument, sample and timingIncorporating the above six inter-relating and overlapping forms of MG/DO arising in the experiences of GAD patients and HCPs, two quantitative survey instruments were defined, one for people with GAD and for people without GAD (for comparative purposes using the same survey), and one for GPs in primary care settings. Each was informed by primary literature research into MG/DO, 8 pre-survey one-hour qualitative telephone interviews with GAD persons of mixed gender and age living in England (conducted in March 2023), and 12 one-hour qualitative telephone interviews with a mix of HCPs in primary and secondary care settings in the UK (May 2023). Note that the GAD/non-GAD patient survey asked about people’s MG/DO experiences with several kinds of HCPs, not just GPs.The two surveys were launched at different times in 2023. The GAD and non-GAD patient survey ran for three weeks in May 2023. The HCP survey ran for two weeks over the end of August and early September 2023.For survey one (patient), 237 people aged 18+ who currently have Generalised Anxiety Disorder (GAD) were recruited from or in collaboration with the Anxiety UK membership network. For comparison, 259 people aged 18+ without Generalised Anxiety Disorder (GAD) were recruited from a market research company sample panel.For survey two (GP), 200 GPs responded, all of whom having reported having a consultation about a physical health condition with at least one patient who had Generalised Anxiety Disorder (GAD) within the past two years. This sample included 154 GPs without extended roles/special interests and 46 with extended roles/special interests.Next, we summarise the survey findings.

This paper presents primary research into the medical gaslighting (MG) and diagnostic overshadowing (DO) of people who have generalized anxiety disorder in UK.

Method: Medical Gaslighting and Diagnostic Overshadowing of Patients with Generalised Anxiety Disorder in the UK: Evidencing and Addressing the Problem.

Christopher Lawer reports financial support was provided by Anxiety UK. Christopher Lawer reports a relationship with Anxiety UK that includes: consulting or advisory. If there are other authors, they
declare that they have no known competing financial interests or personal relationships that could
have appeared to influence the work reported in this paper.

People with generalised anxiety disorderAlthough thought to be under-diagnosed (fewer than half of people with the condition seek treatment), and under-treated (fewer than a third obtain adequate treatment) [1], approximately 5% of the adult population of high-income countries like the UK live with GAD. This amounts to 2.3 m people in the UK (NICE, 2023). Further, around two-thirds of all people diagnosed with GAD are female. Often arising in people’s early thirties, a recent population cohort study found that between 2014 and 2018, GAD rates increased sharply in both males and females aged 18–24 years and 25–34 years, although again its prevalence was more pronounced in young women.&nbsp;Common symptoms of GAD include feeling restless or worried, having trouble concentrating or sleeping, and experiencing dizziness or heart palpitations. Notably, GAD and depression are frequently comorbid: About 62% of people with GAD have at least one episode of major depressive disorder during their lifetime [1].OBJECTIVESAs the UK’s leading anxiety charity, we have heard lots of anecdotal evidence of MG/DO from people with GAD. In embarking on primary research into these reports, we set ourselves three objectives for each of the two primary actors involved. First, for people with GAD, we want to determine the extent of MG/DO arising in their interactions with HCPs in different healthcare settings. Second, we wish to better understand its different forms and their consequences. Third, should this evidence support our anecdotal insight, we wish to learn what resources and tools might be useful for people with GAD to help them secure better healthcare outcomes.Importantly, we seek to better understand MG/DO from a healthcare practitioner perspective too. Given the evidence that MG/DO arises most often in primary care, and the gatekeeper role of GPs in determining a patient’s access to treatments and specialist secondary / acute care, we chose to research the MG/DO experiences and views of GPs. Again, here we had three objectives. First, we wanted to determine the scale of the MG/DO issue as perceived by GPs. Second, we sought to understand why they believe MG/DO happens. Third, we wanted to learn what they are doing and would like to do to reduce its occurrence.

Medical Gaslighting and Diagnostic Overshadowing of Patients with Generalised Anxiety Disorder in the UK: Evidencing and Addressing the Problem.

Why Study? Medical Gaslighting and Diagnostic Overshadowing in People with Generalised Anxiety Disorder

In the past few years, there have been an increasing number of commentaries on the issues of medical gaslighting [1-5] and diagnostic overshadowing [6-8] in patient-clinician encounters. The two phenomena are closely related; medical gaslighting (MG) occurs when a patient’s expressed or observed symptoms pertaining to a physical health condition are incorrectly (or believed by the patient to be incorrectly) dismissed or denied by a clinician. Originating as a term from the controlled manipulation of a person’s actual reality via the means of a gaslight in the 1944 Ingrid Bergman film of the same name [9], MG is not altogether positively received in the medical community [10]. Diagnostic overshadowing (DO) is a similarly contentious term that can provoke strong reactions. It arises when a patient receives a diagnosis that is attributed to a pre-existing or new mental illness for their reported symptoms of a physical health condition.MG/DO arise disproportionately in certain patient populations and for particular types of physical conditions. The former include adults and children with autism, mobility disabilities, learning disabilities, low health literacy, obesity, history of substance abuse and psychiatric or mental health disorders [8]. The latter includes conditions where clinical standards and diagnostic capabilities are either lacking or developing (e.g., long covid, chronic primary pain), and/or where patient reports of their symptoms rely heavily on their subjective expression and their (sometimes diminished) capacities to express them.In this research, we wish to reveal, understand and find ways to address the prevalence and forms of MG/DO that are experienced by people with generalised anxiety disorder or GAD in the UK.

Problems of medical gaslighting and diagnostic overshadowing of people who have generalised anxiety disorder.

Title	DOI	Published date
Implementation of Anxiety UK’s Ask Anxia Chatbot Service: Lessons Learned	10.2196/53897	2024-06-17
Implementation of Anxiety UK’s Ask Anxia Chatbot Service: Lessons Learned (Preprint)	10.2196/preprints.53897	2023-10-23

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