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Some participants recalled experiences where their reports of being physically unwell where passed off as being part of their mental illness. This process is referred to as diagnostic overshadowing were the diagnosis of mental illness overshadows everything else about the person. Therefore concerning reporting symptoms of physical illness practitioners default to a mental illness cause and not a legitimate physical symptom. Diagnostic Overshadowing is intimately linked with stigma; it is stigma in action. I felt that it was an issue that deserved a theme in its own right. Participants commented that

Kathy: To be quite honest I’m surprised that they don’t do whole care because if somebody has got bipolar, you know people talk about sugar rush or whatever or they can become so weak that they can’t get up, you’d have thought that they’d look at the total condition but one is just treated as a matter of fact without any facts being examined for that individual and the other one, the mental health problem is the one that they throw the medication at, whereas I thought that maybe I’d have reached this stage of recovery a lot earlier if my whole health had been looked at...it’s just it’s a larger one with hyper mania so that can be confused with somebody going manic, you know…”

Mary: “I find that nurses tend to be, can be very cold, very like dismiss you if you’ve got mental health problems but you’ve got physical problem as well but that doesn’t matter…I’ve had black outs and everything and sleep attacks because I haven’t been given my medication by the nurses and I did make them aware and I did tell them I didn’t have my medication all day… because in hospitals mental health, the minute that word is mentioned it’s like you’re suddenly nothing, a nobody, you’re like, you know whatever you're saying you’re lying or you’re faking it or you’re just a waste of time, wasting their time”

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John: I was thinking just now that I want to, I think it might be relevant to this, I was having a lot of problems with my feet, previously I was very active, I did a lot of activity, I love walking but I was actually finding it very difficult to walk and the general feeling around me was that I’m lazy or I can’t be bothered, I’m trying to avoid these walks but of course I was avoiding them because I was hurting but it got mixed up with the emotional context of it, people thought I didn’t want to go out and do things with them and stuff like that and it got very frustrating, people around me got very frustrated with me.

Paul: I went to Greece about 3 years later and on about the 4th last day I was there, it was incredibly hot, it was May, one of the hottest Mays they’ve ever had and it was about 38/40 and I was getting like rashes all round my face and they were basically because I was getting yeast infections in the creases of my face and that is a sign post to diabetes. So when I came home I’d forgotten that they’d said, you know 3 years earlier that you’re on the verge of getting diabetes and I looked on the internet and when I worked out that it was basically like some sort of fungal rash, one of the indications was that you could have diabetes. I went to the doctor straight away and I said I think I might have diabetes, they tested my urine, it was quite high, it was over 8 in my urine and they did some blood tests and it was over 8 and they said yeah. They sent me to the hospital and I was past borderline then. They immediately started me on treatment and it took me about a year, 2 years to be able to take the medication.

Some participants’ mental illness diagnosis was linked to the potential for self- harming behaviour with their diabetes medication. This appears to be another aspect of diagnostic overshadowing where mental illness behaviours (in this instance self- harm) appear to be given a higher priority than the physical illness, diabetes.

Jennifer: To be honest with the care coordinator, in terms of whether I was using my insulin or thinking about using my insulin in that crisis, to be honest I hadn’t thought of it and what was least helpful was the thought had then been planted in my mind…not that I’ve ever acted on that or wanted to act on that but that to me was least helpful, that it was actually seen as another way of self- harming.

The problem with stigma and diagnostic overshadowing is that they can become barriers to timely care; if MHNs do not believe or investigate symptom reports, then it opens the up the risk of people living with untreated, or poorly managed diabetes. The consequences of the complications of this were clear for John;

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John: I was told that I’ve lost about 90% of the feeling in my feet by the time I was diagnosed and I’m thinking yeah but I was telling you 5 years ago that I had problems with my feet, so how has it got to this stage before you actually do anything about

When directly asked one participant reported that they had never experienced diagnostic overshadowing in their interactions with practitioners.