"Not Otherwise Specified"

[235750]

Hi everyone,

I'm a med student who's been shadowing psychiatrists for the last several months. I'm learning the basics (201 vs. 302 procedures, common axis 1/2 disorders, etc). Right now I am having trouble with the use and purpose of NOS

One of the psychiatrists on staff uses this phrase quite often. When I asked exactly what that meant, he/she explained that the pt seemed to have a particular disorder, but that not all the official criteria were satisfied. Still, the clinician in question had 'strong' feelings that this diagnosis was correct

I didn't question the doctor any further (last thing I want to do is piss people off), but the explanation was confusing. May a physician override the criteria for a disorder set out in the DSM any time they want? Or just under certain circumstances/disorders? Or does NOS imply that we don't really know what it is, but we're going to try some sort of treatment to see if it works? Is using NOS seen as lazy?

I wish I could give details about specific cases, but I'm too paranoid about internet forums. I don't even give away gender-specific pronouns!

Thanks!

---

Members don't see this ad.

 

[whopper]

An NOS diagnosis should be given if the doctor believes the person has a psychiatric mental condition (By DSM standards--that condition creates a pattern of behavior that causes harm to the person or others) that does not fit the typical DSM guidelines, or did not have enough information at the time of diagnosis.

For example if someone came in with several signs of schizophrenia, but did not give me enough information to dx him with it (e.g. gave me no history, no history was available so I don't know if he's had the signs and sx for over 6 months), then in that situation a psychosis NOS dx is justified.

In those cases, the doctor should still take action to fit the missing pieces to understand the disorder as a whole. Reason being is that giving a more specific diagnosis will allow that doctor and others to better understand the problem, and thefefore treat more appropriately.

Or if someone is psychotic, but it doesn't cleanly fit in the regular psychotic do categories. I've rarely ever seen this happen. Almost every single time I've seen someone psychotic, it was not a true NOS situation. It was either the person had a more typical disorder such as schizophrenia, or there was not enough information at the time.

From personal experience, the majority of times someone has a psychiatric disorder, they will fit into the non-NOS DSM IV categories. In some rare instances you'll have someone who doesn't cleanly fit into it.

Take for example passive aggressive personality disorder which was in the DSM III, and only in the DSM IV as an example of personality disorder NOS. I've seen people truly have that disorder and therefore would fit into the NOS category by DSM IV standards.

In that situation, the NOS was perfectly justified, and it's not a sign of simple laziness on the doctor's part.

An NOS disorder should not be used because the doctor just wants to slap a diagnosis without a good faith effort to figure out what's going on. I think that goes on more often than we would like it. Also take into account that there are circumstances where the doctor will have no choice. In addition the above example where there was no history available, as an ER psychiatrist, you could be in a situation where one patient becomes so violent that you could not in good faith devote the appropriate amount of time obtaining the history for a diagnosis. You had to spend most of your time on that one patient, and process the others.

An NOS diagnosis for a true condition that does not cleanly fit the other DSM criteria should be described in detail so others will understand. For example if someone had passive aggressive personality DO, write down the specific traits that would allow it to fit a personality DO so others will understand what you mean when you diagnose someone with a PD.

 

[kugel]

In emergency psych, it's quite common for me to dx an "NOS" because there are multiple problems that might be from several disorders, or I simply do not have enough info to be at all sure. But I always try to include a notation of the "rule/out" diagnoses in order to let others know what specific disorders I was considering.

By the time the pt is discharged from the inpt ward 2-5 days later, I expect 90% of pts to have a specific diagnosis - but a few will still have symptom clusters that simply do not correctly fit (even loosely) a specific diagnosis.

Remember, the DSM was never meant as a bible of psychiatric diagnosis. It was developed as a tool for researchers around the world, so that they could have a consensus about what symptoms are included in an identifiable symptom cluster - so that what researchers are studying in Oslo under the dx Schizophrenia is essentially the same as what researchers in Sacramento are calling schizophrenia. It has come to be used by payors as a list of "acceptable" or "billable" diagnoses - but there is nothing legislating that psychiatrists are not allowed to write down any diagnosis they want. But doing that will get the treatment unpaid by any insur company and it will make it nearly impossible for the next MD to know what is meant.

 

[235750]

Take for example passive aggressive personality disorder which was in the DSM III, and only in the DSM IV as an example of personality disorder NOS. I've seen people truly have that disorder and therefore would fit into the NOS category by DSM IV standards.

Wow, great response, thank you Whopper! I think I understand now. It seems like from what you and Kugel are saying, it can either by a temporary placeholder, or that it can be part of a bonified psychiatric diagnosis.

Remember, the DSM was never meant as a bible of psychiatric diagnosis. It was developed as a tool for researchers around the world

I suppose that some of my misunderstanding stems from my lack of knowledge regarding the DSM. I am still a little confused as the DSM website says that it is...

"...considered the ‘bible’ for any professional who makes psychiatric diagnoses in the United States and many other countries."

Is this wrong? Is seems Kugel that what you were describing in terms of researchers have a consensus as to what a disorder is would be equally helpful to clinicians attempting to treat patients. I'm not sure how disease definitions are only useful to researchers. May you elaborate?

 

[OldPsychDoc]

Wow, great response, thank you Whopper! I think I understand now. It seems like from what you and Kugel are saying, it can either by a temporary placeholder, or that it can be part of a bonified psychiatric diagnosis.



I suppose that some of my misunderstanding stems from my lack of knowledge regarding the DSM. I am still a little confused as the DSM website says that it is...

"...considered the ‘bible’ for any professional who makes psychiatric diagnoses in the United States and many other countries."

Is this wrong? Is seems Kugel that what you were describing in terms of researchers have a consensus as to what a disorder is would be equally helpful to clinicians attempting to treat patients. I'm not sure how disease definitions are only useful to researchers. May you elaborate?

Hmm--it's gone from tool to "bible" to...
I fear it may be only a matter of time before DSM-V becomes sentient and begins eliminating the "impure" of thought...

 

[whopper]

There's several doctors I believe who use NOS out of laziness, and others who do it because the person really does fit into an NOS category.

IMHO, if someone does have an NOS, and the doctor had the time to fill the missing pieces, they should describe why the person has an NOS dx.

I mentioned this in the past, but one of the nurse managers I worked with used to call the NOS dx "FOS" (full of $hit) because where I used to work, other doctors used it too liberally and due to laziness.

By the time the pt is discharged from the inpt ward 2-5 days later, I expect 90% of pts to have a specific diagnosis - but a few will still have symptom clusters that simply do not correctly fit (even loosely) a specific diagnosis.

Agree. I never scientifically measured it, but when I first see a patient, I'm only about 55-70% confident I have the diagnosis right. By about day 3-5, with the additional input of the treatment team, and collateral information from the social worker, I'm about 90-95% confident.

While the DSM is only supposed to be a guideline, and the book clearly mentions that, most patients (over 90% at least from my experience) I've noticed do fit within its non-NOS guidelines. I've been in too many situations where a doctor puts an NOS, and multiple disorders, only to find that the person had 1, and only 1 true DSM disorder.

It depends on the quality of the practitioner. After you've worked with a few doctors for a few months you can tell the quality of the other doctors.

Just another example as an educational tool....

I had a patient who came into my forensic unit who was clearly psychotic. He was violent, disorganized and couldn't speak complete sentences and highly irritable. With Risperdal, he cleared up.

Yet even at his worst psychotic moments, he kept his room meticulously clean. He in fact neatly folded his laundry before he put it in the washer. The staff and I suspected he had OCD in addition to schizohprenia. Since he was too disorganized to hold an interview, he wouldn't give me enough sx for me to dx him with it, and because his psychosis may have been causing the behavior, I held off on diagnosing him with OCD

(and by the way, it's pretty much unheard of for someone to be disorganized on his level, but be able to keep their room clean and fold their clothes).

After 2 months, I got him to what I believed was his baseline before he became psychotic. During interviews, he still wouldn't mention symptoms of OCD, and he continued his excessive cleaning such as folding his laundry to meticulous detail before throwing it in the washer. He only answered yes or no and appeared to be excessively servile. "Yes sir!" (while excessively nodding his head). I told him I suspected he had OCD and we tried him on an SSRI which reduced his excessive cleaning.

I put down Anxiety DO NOS, but wrote down that in my opinion it probably truly was OCD, but I didn't have enough evidence to back up a true OCD diagnosis.

 

[Danae00]

.

 

[kugel]

I suppose that some of my misunderstanding stems from my lack of knowledge regarding the DSM. I am still a little confused as the DSM website says that it is...

"...considered the ‘bible’ for any professional who makes psychiatric diagnoses in the United States and many other countries."

Is this wrong? Is seems Kugel that what you were describing in terms of researchers have a consensus as to what a disorder is would be equally helpful to clinicians attempting to treat patients. I'm not sure how disease definitions are only useful to researchers. May you elaborate?

Sorry, didn't mean to imply that it's NOT useful to clinicians. Of course it's tremendously useful to have a shared definition of these complicated and sometimes esoteric diagnoses. But it may be helpful to understand the purpose of it's creation and that it is not the be-all, end-all of understanding psychiatry - despite what the publishers may think.

For example, ICD-10 is an "accepted" list of diseases/conditions and their coding numbers, everything from disease states (type II diabetes, post-herpetic neuralgia, etc.) to procedures. The World Health Organization developed ICD years ago so there would be a list of conditions from which statistics could be calculated about incidence, measure quality of care, etc. But it quickly became more about billing purposes.
As OldPsychDoc points out, these lists quickly take on a life of their own.
Read about it at http://en.wikipedia.org/wiki/ICD-10
and look at the "Mental and behavioural disorders" section. You will find diagnoses that are NOT in the current DSM.

If you are writing in someone's chart at your private office, you can write in the diagnosis of "4mm round black lump on left of bridge of nose" and there is nothing anyone can do about it - except that you may have trouble getting insurance companies to pay for treating it. But that does not mean your diagnosis was wrong. Your diagnosis conveys exactly what you meant when you see the pt again and it conveys it to other providers (the primary purposes of having a chart at all), and it conveys that you do not yet know for sure what that lump is. Does the fact that this dx is not in ICD-10 mean that you were wrong? Obviously not.
One the other hand, if you use a dx that IS in the ICD, but that does not convey useful info to other providers - what have you done? I was once sent to physical therapy with a diagnosis of "neuropathy of critical illness," but that provided NO information to the therapists as to what they should do for me. The services were reimbursed, but the dx was otherwise useless to have on the chart.

As you work in medicine, every time you encounter the phrase, "that's the way we have to do it," ask yourself why. Is it helpful to the patient? Is it helpful to the organization? Is it helpful to the rest of the treatment team?
If you can understand why it's being done that way, you will be better able to help all those involved.

My organization tries to enforce a rule that every medication order must include the indication as well as the usual name, dose, route, frequency. Many of the providers don't bother because they've never been effectively disciplined for it and they believe it is just some useless, random Joint Commission rule that is meaningless to the pt's treatment. However, this rule has a reason. When I get a pt who is on Tegretol w/o a listed indication, I don't know if he's taking it for epilepsy, or mood stabilization, or general impulse control, or only temporarily taking it to prevent alcohol withdrawal seizures - or whatever. Knowing why he's taking it can make a big difference in how I proceed with treatment. And when the previous provider thinks the rule is just for bureaucratic reasons, and either ignores it or, worse, guesses at the reason just so he has something to write in so as to fulfill the rule, then treatment can go very wrong for the patient.