Diagnostic overshadowing in systemic lupus erythematosus (SLE): A qualitative study.
Harwood, Rupert, Wincup, Chris, D'Cruz, David et al. · Lupus · 2025 · DOI
Quick Summary
This study looked at why people with lupus (SLE) often wait a long time to get diagnosed. Researchers found that doctors sometimes overlook or misinterpret lupus symptoms, attributing them instead to other causes like mental health problems, ME/CFS, or fibromyalgia. This "diagnostic overshadowing" can add years to someone's diagnostic journey and delay the treatment they need.
Why It Matters
This study is important for ME/CFS patients and researchers because it identifies ME/CFS (along with fibromyalgia and mental health conditions) as a potential diagnostic roadblock that delays recognition of other serious conditions. The findings highlight how misdiagnosis or premature diagnostic closure can harm patients by preventing them from receiving appropriate investigation and treatment. Understanding diagnostic overshadowing may help clinicians avoid similar pitfalls when evaluating patients with complex, multisystem symptoms.
Observed Findings
The majority of SLE patients surveyed reported experiencing diagnostic overshadowing
Sustained diagnostic overshadowing (S-DOS) appeared to add multiple years to some diagnostic journeys
ME/CFS, fibromyalgia, and mental health diagnoses were noted as diagnostic roadblocks that delayed SLE recognition
Doctors often failed to connect multiple symptoms as indicators of a single underlying autoimmune condition
Patients sometimes faced moral misattributions (e.g., being labeled as malingering) that discouraged help-seeking
Inferred Conclusions
Diagnostic overshadowing is a significant and potentially modifiable factor contributing to diagnostic delay in SLE
Alternative diagnoses such as ME/CFS, fibromyalgia, and functional/psychosomatic labels can inadvertently block further investigation for serious systemic autoimmune disease
Clinician failure to synthesize multiple symptoms into a coherent disease pattern is a key mechanism of DOS
Moral misattributions and cost-driven cessation of investigation perpetuate diagnostic delay
Remaining Questions
How frequently does diagnostic overshadowing with ME/CFS misdiagnosis occur in actual clinical practice, and what is the typical time added to diagnostic delay?
What This Study Does Not Prove
This study does not prove that ME/CFS diagnoses are incorrect or that all ME/CFS patients actually have lupus—it only shows that in some SLE cases, an ME/CFS diagnosis was given before or instead of the correct SLE diagnosis. The study does not establish causation or quantify how often this misdiagnosis occurs. Because the study relied on patient recollection and was limited to SLE patients, findings may not generalize to how often diagnostic overshadowing occurs in ME/CFS populations.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →