What's an Unspecified Diagnosis?

Unspecified. What an ambiguous term for something as bent on categorization as psychiatric diagnosis! As readers learned on March 13, 2021, 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:

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Ambiguity

The first situation is when a person presents symptoms of a particular disorder category, but pieces of the puzzle are not available, and it's 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 acted restlessly, talking rapidly and incoherently, and her mood was labile. In court, the judge ordered her to have an emergency assessment by the court clinic. In the court clinic, alcohol was on her breath, and police reported she had a baggie containing what they believed was methamphetamine. Being in the state she was, Jenna was unable to coherently answer any questions about her background. Family or friends who could help put the puzzle together are not accessible.

Jenna clearly presented some manic symptoms. However, the clinician was unable to know if Jenna had a history of bipolar disorder and symptoms were accounted for by a manic phase, during which it is not unusual for people to abuse substances, or if symptoms were induced from substances she ingested. Unfortunately, the evaluation setting was not in a medical facility where toxicology screening could answer if methamphetamine was indeed her system. It also needed to be ascertained if an organic problem like thyroid disease may have contributed to Jenna's presentation.

Though the court clinician was sure they witnessed manic symptoms, it was unclear if Jenna's presentation was due to a primary bipolar disorder, or was influenced by substances or organicity. The clinician deemed Jenna posed a risk to herself and required further assessment at a medical facility, triaged Jenna to the hospital.

Given the need to rapidly assess Jenna's safety, and the barriers to complete information gathering, the clinician couldn't make a definitive diagnosis. All that was clear was that Jenna had manic symptoms. Therefore, the correct 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.

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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. The patient may require medical intervention or acute substance abuse treatment, which always trumps attempting general psychotherapy.

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 fitting the presentation. 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. The book Run, Hide, Repeat by Pauline Dakin illustrates the phenomenon taking over a family. This condition would be written: Unspecified Schizophrenia and Other Psychotic Disorder, Shared Psychosis.

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, as noted in Why Road Rage is a 2-Way Street. Despite this, they become enraged by the actions of other drivers. Some social psychology researchers believe it stems from issues of territoriality. 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 low frustration tolerance in ADHD, we would diagnose: Unspecified Disruptive, Impulse-Control, and Conduct Disorder; Road Rage.

Personality disorders not included in the DSM: Ten specific personality disorders are DSM-5 sanctioned, but there are several others that personality disorder aficionados believe are important to recognize. These include the Depressive, Masochistic, Passive-Aggressive, Exuberant/Hypomanic, and Sadistic. Some of these have been included in previous editions of the DSM, like the Masochistic, but removed because it seemed there was too much overlap with Dependent Personality Disorder. Nonetheless, some personality-disordered patients may exhibit symptoms that contrast enough with Dependent Personality, and the clinician wishes to recognize Masochistic Personality. In this case, the clinician would record: Unspecified Personality Disorder, Masochistic.

DSM Essential Reads

What the DSM Can't See

An Atlas of Mental Health

Practice, practice

It might be a little tricky keeping Other and Unspecified straight at the outset, but just remember:

1. Other is for diagnoses included in the DSM that are missing some criteria.
2. 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.