May 18, 2013: “Other” and “Unspecified” enter the diagnostic language of mental health professionals. Perhaps the two most boring headings in the DSM-5, they compensate for their austerity with beautiful utility. How? It is not uncommon to be unable to swiftly arrive at a confident diagnosis, as discussed in the June 10, 2020 post of The New Therapist. Heretofore, we are rescued by Other and Unspecified should, for example, a diagnosis nonetheless need application, such as for billing or a triage setting. Other times we may need to recognize that we have encountered a presentation not defined in the DSM. Though Other and Unspecified are simple terms, grasping an understanding of how and when to apply them can be a bit complicated at first. Let me help clarify….
A little history
In previous DSM editions, there was the Not Otherwise Specified (NOS) category at the end of each family of diagnoses. It wasn’t that long ago, and you may still see Anxiety Disorder NOS, Psychotic Disorder NOS, Personality Disorder NOS, etc. in patient’s histories. While it is really an anachronistic term and no longer codable, NOS is still often the lingo used amongst the treatment community who are used to the term.
NOS was essentially a catch-all for when a patient either didn’t meet full criteria for a particular diagnosis, had symptoms central to a diagnostic category (anxiety, psychosis, etc.) but didn’t really fit into any of the specified disorders, or it was unclear if the psychiatric symptoms were primary, due to a medical condition, or encouraged by substance use. As you may imagine, with an NOS diagnosis, if the evaluator was not incredibly clear in their clinical formulation (AKA “diagnostic write-up”) it would’ve been easy for there to be confusion about the patient.
Due to the potential mass of confusion, in an effort to further diagnostic clarity, the DSM-5 split NOS up into Other and Unspecified, along with providing etiquette on how to address each. Keeping in step with these categories instead of speaking an outdated term will help keep your diagnostic skills sharp. You must be attentive to detail to properly use the terms, and, trust me, you’ll be using them.
“Other” is actually an abbreviation for Other Specified (insert diagnostic category name); for example, Other Specified Sexual Dysfunction, Other Specified Depressive Disorder, etc. In short, we would be most apt to utilize “Other” when there is a clinical presentation largely aligning with a specific diagnosis, but a piece of the puzzle is absent.
Usual reasons for not meeting full criteria may be that symptom duration is thus far less than required, or a symptom or two is missing but the central components of a particular diagnosis are present. In the diagnosis, such details follow in parentheses, as depicted below. Examples are myriad, but let’s look at a few typical situations calling for “Other”:
- A patient meets overall criteria for Generalized Anxiety Disorder, but symptoms have only been present for 3 months instead of 6 to make the full diagnosis.
- Other Specified Anxiety Disorder (Generalized Anxiety of less than 6 months’ duration).
- Someone with a long history of exhibiting a few core features of a personality diagnosis, like Obsessive-Compulsive Personality Disorder, but the four or more symptoms required for a full diagnosis are not present.
- Other Personality Disorder (Obsessive-Compulsive criteria of preoccupation with perfectionism that interferes with task completion; no other symptoms present)
- Symptoms of Anorexia Nervosa, but the person’s weight, although it has dropped, is within or above normal for their age/height/gender.
- Other Feeding and Eating Disorder (Anorexia Nervosa, but patient currently within medically-acceptable weight parameters).
Final thoughts on Other…
Chances are, you have come across situations similar to the above. Some of my students have wondered if it was unethical to ascribe a diagnosis if all criteria of a diagnosis aren’t met. Without a diagnosis we can’t justify the treatment, especially to insurance companies. Clearly, people not meeting full criteria still are suffering and need care; it would be unethical to turn them away. “Other” allows us to conscionably and accurately diagnose the matter at hand and thus treat it. Keep vigilant, however, for should duration stretch or additional symptoms show, the diagnosis must be altered to reflect full criteria is being met. This is important to note because it is indicative of a worsening condition and perhaps the treatment approach needs alteration or additional steps.
Readers may wish to review the DSM-5 “Other” categories at the end of each diagnosis chapter to gain more familiarity. In the upcoming Wednesday post we’ll define “Unspecified,” and review its use.