The Psychiatrist’s List of Cognitive Biases

There is a long list of psychological terms when it comes to patients in the patient-therapist interaction. In some cases, these labels may be used to justify our own shortcomings. When a patient disagrees with our treatment, diagnoses like anti-social and narcissistic personality can be misused. This may be considered a sophisticated form of projection. In their study “Personality Disorder: the Patients Psychiatrists Dislike”, Lewis and Appelby showed that patients given a previous diagnosis of personality disorder (PD) were seen as more difficult and less deserving of care compared to control subjects who were not. So what kind of biases might we, as health professionals, be susceptible to?

Jumping to conclusions. This is closely linked to the issue of causality. Diagnoses like drug-induced psychosis or extrapyramidal side effects fall into this category, whereby we see only one side of the equation without carefully evaluating the association. For example, when a patient presents with EPSE’s, is it always due to the antipsychotic or could the antipsychotic have exacerbated a pre-existing disorder of the subcortical area?

Missing the forest for the trees / Doctor Simultagnosia. Looking through one’s own tinted glasses leads to each specialty viewing things from their own perspective, missing the overall picture.

Consider the following:
Axis 1 diagnosis: Bipolar Disorder treated by psychiatrist with mood stabilisers
Axis 2 diagnosis: Borderline Personality traits treated by DBT
Axis 3 diagnosis: Migraine treated by neurologist and GP with rizatriptan.

Categorically, these may appear as separate disorders to different specialities, but a biological evaluation of common confounders reveals a common pathogenetic process that would explain all three disorders having implications on the overall health of the individual. Exploration revealed the patient had Neuropsychiatric Lupus and Antiphospholipid Syndrome with the MRI showing deep white matter infarcts at age 33. Clearly, the treatment plan needs to be significantly modified to address the true etiology. By missing the forest while focussing on the trees, this patient is on a path toward dementia and early death through cardiometabolic and cerebrovascular complications.

Man with a Hammer Syndrome. If the only tool you have is a hammer, every problem will look like a nail. I recently received a letter from an ADHD specialist advising me that they will only deal with ADHD medication and that mental health services should deal with the rest. As Tom Robbins stated: “To specialize is to brush one tooth. When a person specialises, he channels all of his energies through one narrow conduit; he knows one thing extremely well and is ignorant of almost everything else.”

Appeal to authority. We tend to thoughtlessly obey those we regard as being in positions of authority. Evidence however, tells us otherwise. This has been well described in James Surowiecki’s book, The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economies, Societies and Nations. Sometimes it is best to put together a group of people with open minds and brainstorm a problem.

Herding. We tend to flock together, especially under conditions of uncertainty. During times like these health professionals must attempt to step outside the box and think laterally.

Overconfidence. We are way too confident in our ability, which seems to be an in-built bias that we are unable to overcome without excessive effort. Being 100 percent confident in one’s diagnosis may in fact mean exhibiting a fixed, firm but false belief that leads to inadequate exploration.

Backfire Effect. If you present certain people with evidence that contradicts their beliefs, it will reinforce their existing beliefs all the more. Remember this during your board meetings.

Bystander Effect. People wait for others to take the lead when someone else is in trouble. Oftentimes, one should just make the tough call and lead.

Many of these points resonate with me and have made me more mindful about my personal biases. I hope they are useful to you too. If you can think of some more points, feel free to add them on the comments section below.

This article is written by Dr Sanil Rege. Sanil is a Consultant Psychiatrist and co-founder of He is pursuing an MBA at the Melbourne Business School.  You can follow him on Google+

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