Unspecified. What an ambiguous term for something as bent on categorization as psychiatric diagnosis! As readers learned in Part 1, there is more than meets the eye to boring-sounding classification categories. While Unspecified and Other may ostensibly appear synonymous, there is quite a distinction in terms of diagnostic application.
With Other, a clinician has usually been able to perform a thorough diagnostic evaluation and knows they are essentially observing a particular disorder, minus some criterion. Unspecified, however, is reserved for two different scenarios:
The first situation is when a person presents symptoms of a particular disorder category, but pieces of the puzzle are not available and it is unclear what is causing them. This will be familiar to anyone working in triage settings like psychiatric crisis or emergency rooms. Consider the case of Jenna:
Jenna, who had an arrest warrant, was picked up by police at a bus station. She was acting very restless, talking rapidly, non-stop, and incoherently. In court, the judge orders her to have an emergency assessment by the court clinic. In the court clinic, alcohol is on her breath, and police report that she had a baggy containing what they believe is methamphetamine. Being in the state she is, Jenna is unable to coherently answer any questions about her background. Family or friends who could help put the puzzle together are not accessible. Jenna is clearly presenting some manic symptoms. However, her clinician is unable to know if Jenna has a history of Bipolar disorder and symptoms are accounted for by a manic phase, during which it is not unusual for people to abuse substances, or if symptoms were induced from the substances she ingested. Unfortunately, the evaluation setting is not in a medical facility where a toxicology screening can answer if methamphetamine is indeed her system. It also needs to be evaluated if an organic problem may contributing to the clinical picture. Though the court clinician is sure they are witnessing manic symptoms, it is unclear if Jenna’s presentation is due to a primary Bipolar disorder or is influenced by substances or an organic condition. The clinician deems Jenna poses a risk to herself and in need of further assessment at a medical facility, so she is triaged to the hospital from court.
Given the need to rapidly assess Jenna’s safety, and the barriers to complete information gathering, the clinician can’t make a definitive diagnosis. All that is clear is Jenna has some manic symptoms. Therefore, the diagnosis would be Unspecified Bipolar Disorder (manic symptoms; unclear if primary, related to a substance or other medical complication). In this sort of situation, the clinician would explain in their documentation that Unspecified indicates further evaluation is required.
If a similar matter occurred in an outpatient office setting, whereby it is not clear if complained-of symptoms may be caused by an organic condition, substance abuse, or is primary, it is most ethical to have the patient medically-evaluated before any psychotherapy takes place. As discussed in the Medical Mimicry series of The New Therapist, containing medical conditions and addiction always trumps attempting general psychotherapy. The patient may require medical intervention or acute substance abuse treatment.
Presentations not specifically addressed in the DSM
The second situation where Unspecified is useful is when a patient presents symptoms of a particular diagnostic category, but there is no diagnosis described therein of which the symptoms are specific to. Hence, it is Unspecified. Diagnoses follow the algorithm: Unspecified X Disorder, name of condition (and be sure to be descriptive in your clinical formulation [AKA diagnostic write-up] about the unspecified condition.) Some examples include:
- Shared Psychotic Disorder: This is an exceedingly rare condition that the DSM committee no longer felt warranted space in the psychotic disorders chapter. In shared psychosis, or what was historically termed “folie à deux,” the patient has come to believe the delusions, a psychotic symptom, held by someone close to them. Now they, too, are rendered psychotic. This disorder was in the spotlight years ago, during the trial of Elizabeth Smart’s kidnappers, David Mitchell and Wanda Barzee. Barzee was believed to have been so attached to/under the spell of Mitchell, that she took on his delusional beliefs. This condition would be written: Unspecified Schizophrenia and Other Psychotic Disorders, Shared Psychosis.
- Dissociative Trance: The experience of dissociative trance is not uncommon to certain religious and spiritual beliefs, but is usually voluntarily-induced and sanctioned by the religion or culture. At times, clinicians encounter people who involuntarily fall into trance and seem in “possession” that causes them clinical distress and it is abnormal to the religious or cultural beliefs. This condition would be documented: Unspecified Trauma and Stressor-Related Disorder, Dissociative Trance.
- Road Rage: Road rage is a display of impulsive anger. It is an interesting phenomenon in that many who experience it are not moody or angry people. Despite this, they become enraged by the actions of other drivers. Some social psychology researchers believe it stems from issues of territoriality. An upcoming post will address working with patients with road rage. If the rage exists in a vacuum, e.g., the Road Rage is not accounted for by a general pattern of Intermittent Explosive Disorder, a manic episode, or due to low frustration tolerance of ADHD, we would diagnose: Unspecified Disruptive, Impulse-Control, and Conduct Disorder; Road Rage.
- Personality Disorders not included in the DSM: 10 specific personality disorders are DSM-sanctioned, but there are several others that personality disorder aficionados believe are important to recognize. These include the Depressive, Hypomanic, Hysterical (not to be confused with Histrionic, included in the aforementioned 10), Masochistic, Passive-Aggressive, and Sadistic. Some of these have been included in previous editions of the DSM, like Masochistic Personality Disorder, but removed because it seemed there was too much overlap between it and Dependent Personality Disorder to justify inclusion. Nonetheless, some personality-disordered patients may exhibit symptoms that contrast enough with Dependent Personality, and the clinician wishes to recognize this condition. In this case the clinician would record: Unspecified Personality Disorder, Masochistic.
It might be a little tricky keeping Other and Unspecified straight at the outset, but just remember:
- Other is for diagnoses included in the DSM that are missing some criteria.
- Unspecified is reserved for etiological ambiguity or conditions that don’t line up with anything in a particular diagnostic category.
Readers may wish to practice with DSM clinical casebooks, which include numerous examples of both Other and Unspecified.