Understanding the Global Assessment of Functioning Scale
- What is the Global Assessment of Functioning Scale?
- GAF Scoring – What Does it Mean?
- When and Why Your Loved One Might Be Assigned a GAF Score
- The History and Shortcomings of the GAF Scale
What is the Global Assessment of Functioning Scale?
The Global Assessment of Functioning Scale (GAF) was introduced by the American Psychiatric Association in 1987 within the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a reference publication used to standardize diagnostic categories and conditions.
The GAF Scale represents the fifth stage of the multi-axial assessment process that clinicians and physicians may use to determine an individual’s level of psychosocial functioning:
- Axis I - Clinical Disorders (anxiety, dementia, etc.)
- Axis II - Personality Disorders (OCD, aggressive, etc.)
- Axis III - General Medical Conditions (diabetes, heart disease, etc.)
- Axis IV - Social and Environmental Problems (life stressors, family issues, etc.)
- Axis V - Global Assessment of Functioning
GAF Scoring – What Does it Mean?
A clinician, whether or not familiar with a patient and his/her history, assigns a numeric score to represent the severity of that person’s psychological symptoms and/or daily functioning. The three areas examined by the GAF are:
- Psychological - obsessions, panic attacks, etc.
- Social and Interpersonal - maintaining friendships, personal hygiene, etc.
- Occupational - work attendance, ability to follow directions, etc.
The GAF scoring system works on a numeric scale from 0-100, broken down into groups of ten. The following table represents the most recent revisions of the GAF Scale as they appear in DSM-IV-TR (Text Revision), released in 2000:
|Score||Assessment of Symptoms|
|100-91||No symptoms. Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities.|
|90-81||Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).|
|80-71||If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social or occupational functioning (e.g., temporarily falling behind on projects).|
|70-61||Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social or occupational functioning (e.g., theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.|
|60-51||Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers).|
|50-41||Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social or occupational functioning (e.g., no friends).|
|40-31||Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work, family relations, judgment, thinking, or mood (e.g., avoids friends, neglects family).|
|30-21||Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no home or friends).|
|20-11||Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).|
|10-1||Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.|
The clinician typically rates the patient’s GAF in relationship to the “current period,” which will vary depending on the guidelines of the program requesting a GAF score. In different circumstances the “current period” may encompass the past week, the past month, the past six months, etc. There is also an option for reporting a person’s GAF score at the highest level of existence over the past year. The assessment is designed to be administered in as few as three minutes.
When & Why Your Loved One Is Assigned a GAF Score
The GAF assessment method is frequently employed by managed care providers when deciding if an individual requires psychiatric treatment and if he or she qualifies for in-patient or out-patient services. The patient may be re-assessed at intervals to determine the appropriate continuation of care.
In addition, if your loved one applies to receive federal, state or workers’ benefits based on mental health need, a GAF score might be required or used in conjunction with other data to determine program eligibility. For example, if a senior is applying for Social Security Disability Insurance (SSDI) benefits because he or she is unable to maintain viable employment due to psychiatric issues, a GAF score of 50 or below is one factor said to indicate an inability to work.
The following agencies have mandated the use of GAF scoring when evaluating a client’s eligibility to receive mental health benefits:
- The U.S. Department of Veterans Affairs
- The California Division of Workers’ Compensation
- Many insurance carriers
The History and Shortcomings of the GAF Scale
The furthest predecessor of the GAF Scale was the Health-Sickness Rating Scale (HSRS), published in 1962. The HSRS was also based on a 0-100 point rating system, although the stages were reversed to interpret the highest scorers as the individuals least able to function. The Global Assessment Scale (GAS), developed in 1976, was the next method of determining psychosocial level of functioning.
After the GAF Scale was adopted in 1987, this scoring system was retained in the next version of the Diagnostic and Statistical Manual of Mental Disorders – DSM-IV, 1994. The GAF was modified for better understanding in DSM-IV-TR.
Despite the year 2000 revisions, many experts question the GAF Scale in terms of its reliability and the lack of validity it shows when predicting the future. The GAF Scale is also criticized for integrating three different dimensions of functioning into one total score, rather than examining each aspect of the patient’s life separately.
For example, because a person’s lowest score in all areas is used, the GAF’s current form suggests that an individual who poses a physical threat to herself should be assigned a score below 20, despite her competent level of functioning at home and within personal relationships.
Perhaps the biggest shortcoming of the GAF Scale is its lack of standardization. The scoring is highly subjective, which means that an individual could be assessed by two clinicians on the same day yet may still walk away with significantly different scores. Also, no standardized guidelines exist for a universal rating system. For example, the U.S. Veterans Association has its own guidelines for scoring, while other programs utilize entirely different sets of guidelines.
A new version of the DSM is scheduled for release in May of 2013. It is expected that this update will include clearer instructions for scoring the GAF, along with possible other reforms and improvements to this method of determining a person’s level of functioning.
Written by Senior Homes writer Mckenzie Fritch.