When the diagnosis misses the root cause: women, psychiatric misdiagnosis and the physical conditions underneath

Why women's physical symptoms get filed under 'mental'

A large review of how gender shapes healthcare found that women's pain and physical symptoms are more likely than men's to be attributed to emotional or psychological causes (Samulowitz et al., 2018). Population data from Denmark covering millions of patients found that women were, on average, diagnosed later than men across hundreds of diseases (Westergaard et al., 2019).

Some conditions show the pattern clearly. Endometriosis diagnosis takes many years in several European studies (Hudelist et al., 2012). In a large survey of people with postural tachycardia syndrome (POTS) — a form of dysautonomia that is far more common in women — many reported being told their symptoms were anxiety or psychological before they were diagnosed (Shaw et al., 2019).

None of this means a doctor was careless. Symptoms like fatigue, racing heart, poor concentration, low mood and worry genuinely overlap between psychiatric and physical conditions. The problem arises when the first explanation becomes the only one, and the physical work-up never happens.

A psychiatric diagnosis and a physical diagnosis are not mutually exclusive. Very often the answer is 'both' — and treating only one leaves you only partly better.

Physical conditions that can look psychiatric

This list isn't exhaustive and it isn't a self-diagnosis checklist. It is a set of conditions that are worth having on the table when mood, anxiety or cognitive symptoms don't fully make sense — so that you can ask whether they have been considered.

• Thyroid disorders: both underactive and overactive thyroid can cause low mood, anxiety, fatigue and poor concentration (Hage & Azar, 2012). A meta-analysis also found depression and anxiety were more common in autoimmune thyroiditis (Siegmann et al., 2018) — which is why thyroid antibodies, not just TSH, can be useful.
• Vitamin B12 deficiency: a classic study showed B12 deficiency can cause neuropsychiatric symptoms even before anaemia appears on a blood count (Lindenbaum et al., 1988).
• Iron deficiency: a large database analysis linked iron deficiency anaemia with a higher risk of several psychiatric disorders (Lee et al., 2020). Heavy periods make this especially relevant for women.
• Coeliac disease: depression and anxiety are more common in people with coeliac disease, and symptoms can be subtle (Zingone et al., 2015).
• Hormonal transitions: PMDD, the postnatal period and perimenopause can all present as anxiety or depression first. I have written separately about these.
• POTS and other forms of dysautonomia: palpitations, breathlessness, dizziness and brain fog are easily mistaken for panic (Shaw et al., 2019).
• Rarer but serious: autoimmune encephalitis, such as anti-NMDA receptor encephalitis, can present with sudden psychiatric symptoms in young women and is treatable when recognised (Dalmau et al., 2008).

Why the first label tends to stick

Medicine has a name for one of the ways this happens. Emergency physician and diagnostic-error researcher Pat Croskerry described 'diagnostic momentum', where a label gathers weight each time it is passed from one clinician to the next until it is treated as settled, and the 'psych-out error', where physical illness is missed in someone who already has a psychiatric diagnosis (Croskerry, 2003). These are thinking shortcuts that affect everyone, not signs of bad doctors.

In practice it can look like this: once 'anxiety' is in your notes, new symptoms are more easily read through that lens. A racing heart becomes panic, exhaustion becomes low mood, pain becomes stress. Knowing this pattern exists makes it easier to ask, calmly, for the physical possibilities to be looked at again — especially when something new appears or an existing treatment isn't helping as expected.

It is often both, not either/or

Older research that systematically screened psychiatric patients for physical illness found a meaningful number of previously unrecognised medical conditions, some of which were contributing to their symptoms (Koran et al., 1989). That doesn't mean their psychiatric diagnoses were wrong. Living with an untreated thyroid condition or chronic pain can absolutely cause depression; depression can absolutely make pain and fatigue worse.

So when a physical cause is found, I encourage women not to rewrite their whole story as 'it was never real'. The suffering was real. The diagnosis may have been incomplete. Both medical and psychological support may still be needed while the physical condition is treated — and that is a decision to make with your prescriber, step by step.

Please don't stop your medication

If something in this article resonates, the next step is a conversation, not a change. Stopping antidepressants, mood stabilisers, antipsychotics or anti-anxiety medication suddenly can cause withdrawal effects, which for some people are severe and long-lasting (Davies & Read, 2019), and can risk a relapse of the original condition. The Royal College of Psychiatrists recommends any reduction is planned and gradual, with your prescriber.

Finding a thyroid, iron or hormonal problem does not automatically mean a psychiatric medication is no longer needed. Sometimes it is; sometimes it isn't. That judgement belongs with the professionals who know your history, ideally working together.

Never stop or change a psychiatric medication on your own. Bring your questions to your prescriber and make any change together, slowly and with support.

How to ask better questions

Asking questions is not being difficult. It is participating in your own care. These are the questions I encourage clients to take to their GP or psychiatrist:

• 'Before we settle on this diagnosis, what physical causes have we ruled out?'
• 'Could we check a full blood count, ferritin, B12, folate, vitamin D, thyroid function with antibodies, blood sugar or HbA1c, and coeliac screening if they haven't been done recently?'
• 'My symptoms seem to follow my cycle, a pregnancy or changes in my periods — could hormones be part of this?'
• 'Did any of these symptoms start after a new medication, an infection or a major life event?'
• 'My heart races and I feel faint when I stand — could we look at that before calling it panic?'
• 'Would it be reasonable to get a second opinion or a specialist referral?'

Second opinions and practical advocacy

In the UK you are entitled to ask for a second opinion, although it isn't a legal right and the GP or consultant decides whether to refer. In South Africa, and in private care generally, you can usually choose another practitioner. A second opinion is a normal part of medicine, not an insult to anyone.

Bring a written symptom timeline: when things started, what makes them better or worse, any links with your cycle, food, posture, sleep or medication. Ask for copies of your results with the actual numbers, not just 'normal'. Take someone with you if you find appointments overwhelming. And if you are told 'it's anxiety', it is fair to ask, 'What would make you reconsider that?'

Where a nutrition practitioner fits

My role is not to diagnose psychiatric conditions or to manage psychiatric medication. It is to look at the whole picture — nutrient status, blood sugar, gut health, hormones, sleep, stress — help you understand your results, and support you to raise the right questions with your doctor. I always work alongside medical care, never instead of it, and I will refer back when something needs medical attention.

Many of the women I work with have had both a real mental health condition and an under-recognised physical one. Treating the whole person, rather than choosing between mind and body, is usually where things start to shift.

If you need support now

If you are having thoughts of harming yourself or ending your life, please reach out now: in the UK call Samaritans on 116 123 (free, 24/7); in South Africa call the SADAG suicide crisis line on 0800 567 567; or contact your local emergency services. You deserve support today, not after the next appointment.

Before you act on any of this

This article is for education and general information only. It isn't medical advice, it can't diagnose or treat any condition, and it doesn't replace a consultation with your own doctor or a qualified practitioner who knows your history. Please don't start, stop or change any medication, hormone or supplement because of something you've read here — take your questions to the person responsible for your care.

References

• Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775–780.
• Dalmau, J., Gleichman, A.J., Hughes, E.G., et al. (2008). Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. The Lancet Neurology, 7(12), 1091–1098.
• Davies, J., & Read, J. (2019). A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: are guidelines evidence-based? Addictive Behaviors, 97, 111–121.
• Hage, M.P., & Azar, S.T. (2012). The link between thyroid function and depression. Journal of Thyroid Research, 2012, 590648.
• Hudelist, G., Fritzer, N., Thomas, A., et al. (2012). Diagnostic delay for endometriosis in Austria and Germany: causes and possible consequences. Human Reproduction, 27(12), 3412–3416.
• Koran, L.M., Sox, H.C., Marton, K.I., et al. (1989). Medical evaluation of psychiatric patients. I. Results in a state mental health system. Archives of General Psychiatry, 46(8), 733–740.
• Lee, H.S., Chao, H.H., Huang, W.T., Chen, S.C.C., & Yang, H.Y. (2020). Psychiatric disorders risk in patients with iron deficiency anemia and association with iron supplementation medications: a nationwide database analysis. BMC Psychiatry, 20, 216.
• Lindenbaum, J., Healton, E.B., Savage, D.G., et al. (1988). Neuropsychiatric disorders caused by cobalamin deficiency in the absence of anemia or macrocytosis. New England Journal of Medicine, 318(26), 1720–1728.
• Royal College of Psychiatrists. Stopping antidepressants. Patient information resource.
• Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). 'Brave men' and 'emotional women': a theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research and Management, 2018, 6358624.
• Shaw, B.H., Stiles, L.E., Bourne, K., et al. (2019). The face of postural tachycardia syndrome – insights from a large cross-sectional online community-based survey. Journal of Internal Medicine, 286(4), 438–448.
• Siegmann, E.M., Müller, H.H.O., Luecke, C., et al. (2018). Association of depression and anxiety disorders with autoimmune thyroiditis: a systematic review and meta-analysis. JAMA Psychiatry, 75(6), 577–584.
• Westergaard, D., Moseley, P., Sørup, F.K.H., Baldi, P., & Brunak, S. (2019). Population-wide analysis of differences in disease progression patterns in men and women. Nature Communications, 10, 666.
• Zingone, F., Swift, G.L., Card, T.R., et al. (2015). Psychological morbidity of celiac disease: a review of the literature. United European Gastroenterology Journal, 3(2), 136–145.