Editores: Sadock, Benjamin J.; Sadock, Virginia A.

; Ruiz, Pedro
Título: Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th Edition
Copyright ©2017 Lippincott Williams & Wilkins

> Table of Contents > Volume I > 12 - Schizophrenia and Other Psychotic Disorders > 12.17 - Other Psychotic Disorders > Other Specified
Schizophrenia Spectrum and Other Psychotic Disorder and Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder and

Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

History
The concept of “unspecified psychosis” was introduced in DSM-II but was specifically noted to be “for librarians and
statisticians to use in coding incomplete diagnoses” rather than for use by clinicians. However, in DSM-III, the diagnosis
of “atypical psychosis” was introduced as “a residual category for cases in which there are psychotic symptoms … that do
not meet the criteria for any specific mental disorder.” DSM-III-R changed the name of the diagnosis to psychotic disorder
not otherwise specified (atypical psychosis) and eliminated mention of the diagnosis as a “residual category.” Instead, it
emphasized the use of the diagnosis for “Disorders in which there are psychotic symptoms (delusions, hallucinations,
incoherence, marked loosening of associations, catatonic excitement or stupor, or grossly disorganized behavior) that do
not meet the criteria for any other nonorganic psychotic disorder.” It also noted that the diagnosis of psychotic disorder
not otherwise specified was preferable to deferring a diagnosis in individuals for whom there was inadequate information
to make a specific diagnosis.

The concept of psychotic disorder NOS persisted with the development of DSM-IV, although the references to atypical
psychosis and nonorganic psychotic disorders were dropped. As in prior editions of DSM, there were no specific
diagnostic criteria for this category. However, it was now defined as including psychotic symptoms
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“about which there is inadequate information to make a specific diagnosis or about which there is contradictory
information, or disorders with psychotic symptoms that do not meet the criteria for any specific Psychotic Disorder.”

The DSM-5 divided the DSM-IV category of psychotic disorder NOS into two distinct categories of “other specified
schizophrenia spectrum and other psychotic disorder” and “unspecified schizophrenia spectrum and other psychotic
disorder” to underscore the reason why the disorder could not be classified as one of the specific schizophrenia
spectrum disorders. While in the other specified schizophrenia spectrum and other psychotic disorder the characteristics
of the condition clearly do not meet the criteria for a specific disorder, in the unspecified schizophrenia spectrum and
other psychotic disorder there is inadequate information to make a more specific diagnosis. The latter diagnosis may
thus be appropriate for acute care and emergency department settings where there is insufficient information available.

DSM-5 provided four examples of other specified schizophrenia spectrum and other psychotic disorder: (1) persistent
auditory hallucinations, (2) delusions with significant overlapping mood episodes, (3) attenuated psychosis syndrome,
and (4) delusional symptoms in partner of individual with delusional disorder. The last example, variously called “shared
delusional disorder,” “shared psychotic disorder,” and “induced psychosis,” and “folie à deux,” was discussed as a specific
psychotic disorder in the previous edition of DSM and in ICD-10. The new category of attenuated psychosis syndrome is a
new category in the DSM and its introduction was associated with some controversy. These two categories are
discussed in some detail later in the chapter.

Comparative Nosology
ICD-10 includes a somewhat related diagnostic category: “F 23.8 Other Acute and Transient Psychotic Disorders.” This
category is used for “Any other acute psychotic disorders that are not classifiable under any other category” in the section
of acute and transient psychotic disorder (see Table 12.17–2). However, like other acute and transient psychotic
disorders, these psychotic conditions are characterized by acute onset and typically brief duration and in this regard differ
from the DSM-5 categories of “other specified” and “unspecified schizophrenia spectrum and other psychotic disorder,”
which have no associated mode of onset or time-related requirements.
Epidemiology
There is minimal information about the prevalence of other specified schizophrenia spectrum and other psychotic
disorder and unspecified schizophrenia spectrum and other psychotic disorder in the community. In clinical practice, the
psychotic disorder not otherwise specified (NOS) diagnosis has been often used in first admission or emergency
psychiatric patients when there is inadequate information to make a diagnosis.

Etiology
Given the heterogeneity of the other specified and unspecified schizophrenia spectrum and other psychotic disorder
diagnoses, it is not surprising that there has been minimal investigation into etiologies of these disorders. However, one
family study has examined the occurrence of other psychotic illnesses in relatives of probands with psychotic disorder
NOS according to prior editions of the DSM and found a substantially elevated risk of schizophrenia and schizophrenia
spectrum disorders in these family members but not mood disorders.

Diagnostic and Clinical Features

The diagnostic category of other specified schizophrenia spectrum and other psychotic disorder includes cases with
psychotic symptoms and clinically significant distress or impairment that do not conform to diagnostic criteria for
specific schizophrenia spectrum and other psychotic disorders. The specific presentation can be recorded as well. For
example, for a patient who present to the hospital with persistent auditory hallucinations that are not accompanied by
mood disturbance and that are not consistent with symptom criteria for schizophrenia or any other DSM-5 category a
diagnosis of “other specified schizophrenia spectrum and other psychotic disorder, persistent auditory hallucinations”
may be recorded. Other examples include psychotic symptoms that are below the threshold for a full psychotic episode
(attenuated psychosis syndrome), delusional beliefs in partners of individuals with a primary delusional disorder, and
persistent delusions with periods of overlapping mood symptoms that have been present for a substantial portion of the
delusional disturbance.

A diagnosis of unspecified schizophrenia spectrum and other psychotic disorder may be appropriate for a patient
presenting with psychotic symptoms causing clinically significant distress or impairment but where information
regarding symptoms and history is not sufficient to make a diagnosis of a specific schizophrenia spectrum and other
psychotic disorder. For example, the clinician may not be able to determine whether the psychosis is primary, due to a
general medical condition, or the result of a substance or medication use. Such distinctions can be difficult to make,
especially when adequate clinical history is not available (e.g., in the emergency department settings).

Differential Diagnosis
Because other specified and unspecified schizophrenia spectrum and other psychotic disorder are diagnoses of
exclusion, the differential diagnosis includes other possible diagnoses with psychotic symptoms. Co-occurring substance
use is one of the most frequent confounding factors in establishing a specific diagnosis, since substance use can be
found in more than half of hospitalized patients with psychotic symptoms. The possibility that a general medical
condition may be causing the psychotic symptoms must always be kept in mind.

If mood symptoms are present, the differential diagnosis will include major depressive disorder with psychotic features
or bipolar disorder with psychotic features, depending on the type of mood change that is present. Schizoaffective
disorder is also possible if the temporal requirements for the psychotic symptoms and mood changes are met.

If no mood symptoms are present and substance, medication, and medical disease can be ruled out as causes of
psychotic symptoms, the differential diagnosis will include schizophrenia, schizophreniform disorder, brief psychotic
disorder, and delusional disorder depending on the duration and type of psychotic symptoms exhibited.

Course and Prognosis

The course and prognosis are highly variable as other specified and unspecified schizophrenia spectrum and other
psychotic disorder are
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heterogeneous. Furthermore, the diagnosis of unspecified schizophrenia spectrum and other psychotic disorder is often
a provisional diagnosis by design that would be changed upon gathering more information. In a first-admission study in
Suffolk County, New York, 12 percent of individuals were diagnosed by the research team with psychotic disorder NOS at
the time of first admission, but only 4.8 percent received this diagnosis by the 6-month follow-up, and by 24-month follow-
up, the rate was 3.9 percent. Of 25 individuals with a diagnosis of psychotic disorder NOS at 6-month follow-up, only 11
maintained this diagnosis by 24-month follow-up, a stability rate of only 44 percent. In addition, 8 of the 25 subjects with
psychotic disorder NOS had met the criteria for schizophrenia or schizoaffective disorder.