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May 18, 2013: “Other” and “Unspecified” enter the diagnostic language of mental health professionals. Perhaps the two most boring headings in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), they compensate for their austerity with beautiful utility.
How? It's not uncommon to be unable to swiftly arrive at a confident diagnosis or to encounter a presentation that does not quite meet full diagnostic criteria. Clearly, people not meeting full criteria still are suffering and need care; it would be unethical to turn them away. Without a diagnosis, we can’t justify the treatment, especially to insurance companies.
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. Today, let me help clarify "Other."
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 general medical condition, or encouraged by substance use.
Unfortunately, it was often applied arbitrarily as a "good enough diagnosis" so long as the symptom category seemed accurate, as if it was an invitation for lazy diagnostic work. However, even when appropriately applied, if the evaluator was not incredibly clear in their clinical formulation (“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.
How to accurately apply Other
“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 criterion or two are 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 three months instead of six to make the full diagnosis: Other Specified Anxiety Disorder (Generalized Anxiety of less than six months’ duration).
- Someone presents with a long history of a baseline pattern of inappropriate, provocative/seductive behavior, preoccupation with superficial appearance, and theatrical expressions: Other Personality Disorder (Histrionic characteristics; meets only three of five symptoms required for full diagnosis).
- 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).
Other is not an invitation for sloppy diagnosing
Clearly, "Other" was meant to be used in a very specific manner for more accurate diagnosing. It applies only when, after thorough review, the patient does not meet the full criteria for a specified condition.
It was not meant to be used as an easy, "good enough" diagnosis so long as the right symptom category is included. Arbitrary application of a diagnosis is essentially saying, "We don't really need to care about what exactly is going on here." How might you feel if you knew a treatment provider gave you "once over" and applied a "good enough" diagnosis, only to discover later that if they were more thorough you could've had more accurate treatment?
"Other" is not meant to be an easy diagnosis, and in fact, comes with more responsibility. This is because clinicians applying "Other" diagnoses must keep extra vigilant, as, 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 category to gain more familiarity. In the upcoming post, we’ll define “Unspecified,” and review its use.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
