Monday, May 6, 2013

NOS Is Dead; Long Live NEC!

In a recent Shrink Rap post on the DSM-5, Dr. Steven Reidbord wrote the following comment:
I don't have much to add regarding DSM 5. I use DSM codes on super-bills I give to patients, so they can receive partial reimbursement by their health plans after paying me directly. Most of the time I use 300.00 (nonspecific anxiety) or 311 (nonspecific depression), and occasionally "parity" codes for major depression etc. I've read all the controversy over the new edition, and it saddens me that our field is so distorted by politics and money. However, I don't see it affecting me much directly.
I have to say that I, too, often use ICD (not DSM) codes 300.00 and 311, which in the DSM-IV are called anxiety disorder not otherwise specified (NOS) and depressive disorder NOS. Working with kids, two other favorites of mine are mood disorder NOS (296.90) and disruptive behavior disorder NOS (312.9). Why such a penchant for such nonspecific diagnoses? Well, for one thing, I believe it truly reflects the patients that I see. I often hear patients or family members talk about "rages" or "anger outbursts" or "mood swings" lasting minutes to hours, none of which are well-captured by a current DSM diagnosis.

I also think that the NOS diagnoses allow clinicians to be humble, by not claiming to know more than we do about the etiology of a patient's condition. Since there are no medications approved to treat NOS diagnoses, to me they feel less "biological." For example, when I say a child has "mood disorder NOS, disruptive behavior disorder NOS, and a parent-child relational problem," I am describing a child that is moody, often has tantrums, and does not get along with his parents. I explicitly say to the parents that I'm not saying there's anything biologically wrong with their child, that these are behavioral problems that can have a multitude of causes, including family dynamics, and that what's going to ultimately make things better is not a pill.

One criticism I've often heard about using a NOS diagnosis is that it is lazy, something done by a clinician who hadn't bothered asking enough questions to reach a firmer conclusion. This is certainly possible. However, in my practice I've generally seen the exact opposite (especially in a Medicaid clinic where I worked): Many patients being diagnosed with schizophrenia or bipolar disorder type 1 or major depressive disorder, when it is clear to me that they never met the criteria for those conditions in the first place. This "mania" for reaching a firm diagnosis, I believe, is largely driven by a need to medicate. If all you have is a hammer, everything looks like a nail.

Thus, I was somewhat peeved to read last year that one of the explicit goals given to the DSM-5 workgroups was:
Eliminate "not otherwise specified" (NOS) diagnoses within categories
The rationale for them wanting to do this is obvious. As blogged about elsewhere, the DSM-5 leadership had hoped to move diagnosis onto a firmer biologically-based footing, and what can be more "fuzzy," biologically-speaking, than diagnoses for which there are only loosely defined criteria? Not surprisingly, the biological psychiatrists had an "epic fail" when it came to biologicalizing DSM-5. Thus, even though DSM-5 has technically eliminated NOS diagnoses, nonspecific conditions will live on in the form of Not Elsewhere Classified (NEC). Here's the difference in their definitions:
NOS: Not Otherwise Specified - This designation is equivalent to the word "unspecified" and indicates that the documentation does not provide enough information to assign a more specific code.

NEC: Not Elsewhere Classified - This designation is used to indicate there is no separate specific code available to represent the condition documented. In this case, the diagnostic statement is specific, but the coding system is not specific enough.
What can I say, except that this actually looks like progress? Clinicians like Dr. Reidbord and myself can not only continue using our fuzzy nonspecific diagnoses, but also instead of having NOS imply that we're lazy clinicians and didn't document enough, we'll be using NEC and implying that it's the coding system (DSM-5) that's inadequate.