Diagnosis is often included in a client’s Biopsychosocial Assessment. It is also required to receive reimbursement for insurance. This article includes information on how you can use DSM 5 to write a diagnosis.

I thought I would include a brief section on diagnosis since there are some changes from DSM-IV-TR to DSM 5. The old DSM diagnosis was divided into 5 Axis. Axis I was the primary disorder that the person came to you for like major depressive disorder or generalized anxiety disorder. Axis II was for disorders that may shape the primary disorder like a personality disorder or developmental disorder. Axis III was for any medical issues that are connected to the person’s current or past psychiatric issues. Axis IV is for stressors like divorce or family issues. Axis V was their level of functioning from a GAF or Global Assessment of Functioning score. The new system can be organized much the same but without the specific Axis.

Sample Diagnosis

This is a very detailed example just to give you an idea of how you can do it. It can be in paragraph form or you can do it in a list form.

  1. Diagnosis
  2. Notations (V codes)
  3. Medical conditions (as reported by the client)
  4. Severity
  5. Treatment considerations

Diagnosis – 296.33 Major Depressive Disorder, recurrent episode, severe, 301.83 Borderline Personality Disorder, Early remission of 305.00 Alcohol Use Disorder, mild
Notations – V15.42 Past history of neglect in childhood, V15.59 Personal history of self-harm
Medical Conditions – Gastritis, severe, Fibromyalgia
Severity – Client’s overall disability is in the severe range. Client’s functioning is affected in home, work and social environments. Major Depressive Disorder is severe due to suicidal ideation. Borderline Personality Disorder is severe due to the effect on social and work functioning. Alcohol Use Disorder is mild as it is in early remission with no use of alcohol for 3 months. Client has history of self-harm which is mild due to low-frequency of use as a coping skill.
Treatment considerations – Referral to Alcoholics Anonymous to prevent relapse of Alcohol Use Disorder, Referral to Psychiatrist, Referral to partial hospitalization program, Suicide contract, Individual psychotherapy 3 times per week to address depression, problems with interpersonal relationships, boundaries and identity issues due to Borderline Personality Disorder. Further assessment of eating disorder and self-harm needed. Further assessment is needed to address abandonment issues.