Diagnostic overshadowing

Picture the GP notes for a patient with a learning disability, opened on the desk. 1. A giant rubber stamp already pressed across the front page: 'LEARNING DISABILITY — EXPLAINS IT' — anchoring on the known diagnosis as the first hypothesis, instead of a fresh differential. 2. Where the presenting-complaint line should be, there's no speech bubble, only a fist banging the desk — communication barrier: pain, low mood, or psychosis can only show up as behaviour change, with no verbal complaint pointing elsewhere. 3. The 'usual behaviour' box on the form is empty, never filled in — no documented baseline: without knowing what normal looks like for this person, a real change can be missed entirely, not just misread. 4. A pair of handcuffs is drawn around the fist itself, not around any diagnosis — behaviour treated as an endpoint: it gets managed (sedation, restraint) instead of investigated as the presenting feature of an underlying cause.