Open access Correspondence
‘Brain on Fire’: an extraordinary
cinematic depiction of the phenomenon
of diagnostic overshadowing
Soumitra Das, Karishma Kulkarni
To cite: Das S, Kulkarni K. Diagnostic overshadowing refers to a diagnosis was considered when there was no
‘Brain on Fire’: an extraordinary phenomenon commonly characterised by apparent investigative finding. The bedside
cinematic depiction
of the phenomenon of
a person with pre-existing or recently diag- clinical lobar function tests conducted by
diagnostic overshadowing. nosed mental illness receiving inadequate her brilliant neurologist ultimately estab-
General Psychiatry attention for symptoms of physical illness, lished the need for a brain biopsy, an inva-
2021;34:e100504. doi:10.1136/ which are then misattributed as manifesta- sive investigation not part of routine practice.
gpsych-2021-100504
tions of the mental illness. There are poten- The brain biopsy established the diagnosis of
Received 01 February 2021 tially several underlying reasons for this, anti-NMDA encephalitis that could be treated
Accepted 23 June 2021 including diagnostic challenges in estab- with plasmapheresis and corticosteroids.
lishing a medical cause for the presenting It is now common knowledge that dramatic
symptoms, likely lack of expertise in medi- psychiatric symptoms can manifest as the
cine, stigma directed towards mental illness, early signs of illness in 60% of autoimmune
a protean or polymorphic presentation encephalitis cases. The misattribution of
not immediately relating to an established these presentations leads to a significant delay
nosology, lack of a reliable evidence base in in instituting effective treatment.2 Adequate
the area leading to an inability to correlate training to increase the knowledge of the
with established medical diagnoses as well appropriate clinical warning signs can lead
as biases towards treating surface-level symp- to a significant reduction in the time taken
toms instead of identifying the underlying to achieve a diagnosis of an autoimmune
causes.1 The movie Brain on Fire is based on neuropsychiatric condition.3 In fact, there
the real life of the New York Post journalist, have been reports of cases of autoimmune
Susanna Cahalan. She is the protagonist of encephalitis, which were diagnosed following
the movie which vividly dramatises a presen- a negative autoantibody test result (31.4%,
tation characterised by psychotic symptoms according to a few studies), leading to further
with an underlying oft-underdiagnosed auto- delays in exact diagnostic identification of the
immune pathology. Her symptoms included condition.4 Furthermore, the access to immu-
subtle perceptual disturbances, fatigue, nological and laboratory testing is limited,
depressed mood and apparent withdrawal. leading to further delays in determination of
Gradually, these progressed to frank para- the diagnosis.5 This process is further compli-
noia and unstable mood. Thus, her presenta- cated in the elderly population whose auto-
tion was quite polymorphic where symptoms immune conditions may not be considered
could have been classified as a psychotic or as differential diagnoses for neuropsychiatric
mood disorder. Further striking changes presentations.6
© Author(s) (or their appeared with the onset of seizure episodes, The film, therefore, contains numerous
employer(s)) 2021. Re-use which pointed towards a neurological illness. lessons. First, it demonstrates the need for
permitted under CC BY-NC. No However, these were disregarded following a a thorough neurological assessment along
commercial re-use. See rights
and permissions. Published by
lack of clear radiographic and electroenceph- with maintaining a high index suspicion for
BMJ. alographic evidences. organic possibility in every ostensibly atypical
Dept of Adult Psychiatry, Eventually, Cahalan was hospitalised psychiatric presentation. Second, a trainee
Melbourne Health, Parkville, following agitation, disorientation and psychiatrist should consider the possibility of
Victoria, Australia multiple seizure episodes. Her family faced diagnostic overshadowing and its attendant
Correspondence to
considerable distress due to an uncertain iatrogenic risks. The film can potentially act
Dr Soumitra Das; diagnosis leading to inconsistent and ulti- as a teaching aid for students of psychiatry
soumitratdmc@gmail.com mately ineffectual treatment. Psychiatric and neurology.7
Das S, Kulkarni K. General Psychiatry 2021;34:e100504. doi:10.1136/gpsych-2021-100504 1
General Psychiatry
Contributors SD formulated the idea, started writing the paper. KK did an REFERENCES
extensive literature search and helped in completing the paper. Both worked for 1 Shefer G, Henderson C, Howard LM, et al. Diagnostic overshadowing
revision and modifying the paper as per the reviewer’s suggestions. and other challenges involved in the diagnostic process of patients
with mental illness who present in emergency departments with
Funding The authors have not declared a specific grant for this research from any physical symptoms--a qualitative study. PLoS One 2014;9:e111682.
funding agency in the public, commercial or not-for-profit sectors. 2 Steiner J, Prüss H, Köhler S, et al. Autoimmune encephalitis with
Competing interests None declared. psychosis: warning signs, step-by-step diagnostics and treatment.
World J Biol Psychiatry 2020;21:241–54.
Patient consent for publication Not required. 3 Herken J, Prüss H. Red flags: clinical signs for identifying autoimmune
encephalitis in psychiatric patients. Front Psychiatry 2017;8:25.
Provenance and peer review Not commissioned; externally peer reviewed. 4 Spindel J, Heckroth M, Marsano L. Antibody-negative autoimmune
Open access This is an open access article distributed in accordance with the encephalitis as a complication of long-term immune-suppression for
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which liver transplantation. BMJ Case Rep 2020;13:e235777.
5 Shahpesandy H, Mohammed-Ali R, Oladosu A, et al. Anti-voltage-
permits others to distribute, remix, adapt, build upon this work non-commercially, gated potassium channel complex antibody-mediated limbic
and license their derivative works on different terms, provided the original work is encephalitis: a case report of a 53-year-old man admitted to
properly cited, appropriate credit is given, any changes made indicated, and the use intensive care psychiatric unit with psychotic mania. Gen Psychiatr
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6 Behrman S, Lennox B. Autoimmune encephalitis in the elderly: who to
test and what to test for. Evid Based Ment Health 2019;22:172–6.
7 Das S, Doval N, Mohammed S, et al. Psychiatry and cinema: what
can we learn from the magical screen? Shanghai Arch Psychiatry
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Dr. Soumitra Das graduated from AGMC, Tripura University in India in 2010. He obtained an MD degree
in Psychiatry from Kerala University in India in 2016. He then completed his senior residency in NIMHANS
(from 2016 to 2018) where he was actively involved in community based research. More than 50 articles
he published have been indexed in PubMed and he took part in various projects. He left India and joined
Melbourne Health in Australia as a senior registrar. He completed FRANZCP in 2021 and soon will become a
college fellow. He is keen on joining large scale projects in neuropsychiatry. He dreams of uncovering mysteries
behind complex mental health issues like resistant OCD or schizophrenia. His main research interest includes
neuropsychiatry.
2 Das S, Kulkarni K. General Psychiatry 2021;34:e100504. doi:10.1136/gpsych-2021-100504