A GAF score is the fifth of five axes outlined in the multi-axial assessment

described by the American Psychiatric Ass=n, Diagnostic and Statistical Manual

of Mental Disorders, Text Revision at 30 (4th Ed. 2000)(revised 2002)(the ADSM-
IV@)(attached hereto as Defendant’s Exhibit 1). Axis I addresses “clinical
disorders and other conditions that may be the focus of clinical attention.” Id. At
27. Axis II addresses “personality disorders and mental retardation.” Id. Axis III
addresses “general medical conditions.” Axis IV addresses psychosocial and
environmental problems such as “problems with [a] primary support group,
problems related to the social environment, educational problems, occupational
problems, housing problems, economic problems, problems with access to health
care services, problems related to interaction with the legal system/crime; [and]
other psychosocial and environmental problems. Id. At 27, 32. Axis V then
assesses functioning overall “with respect…to psychological, social, and
occupational functioning.” Id. At 32.
A GAF score reflects a doctor=s subjective judgment of a patient=s overall
level of functioning -- which may not be based on an assessment of occupational
impairment of any kind, as explained below -- at or about the time the doctor
observes the patient. As is more fully explained below, 0 it “does not directly
correlate with a disability determination under the Social Security Act, functioning
as more of a clinical benchmark or descriptor than an opinion as to a patient’s
limitations caused by a specific impairment. . . . [It] sheds no light on whether
Plaintiff’s medically determinable illness prevents him from working. 0Baker v.
Astrue, CV 08 3199 MLG, 2009 Westlaw 279085 (C.D. Ca. Feb. 9, 2009). “In
some settings, it may be useful to assess social and occupational disability and to
track progress in rehabilitation independent of the severity of the psychological
symptoms.” DSM-IV at 33. The DSM proposes other measurement scales for
those instances. Id.
 The very nature of a GAF score belies its reliability as a measure of
occupational impairments. A GAF score has two components: (1) the severity of a
patient=s psychological symptoms (hereinafter the Asymptom@ component) and
(2) the patient=s functioning (psychologically, socially, and occupationally)
(hereinafter the Aimpairment@ component). DSM-IV at 30. If the severity of
symptoms do not correlate with the degree of the patient=s functional impairment,
i.e., the components are Adiscordant,@ then the GAF score reflects Athe worse of
the two.@ DSM-IV at 32. Thus, a GAF score may reflect an assessment of severe
symptoms but mild impairments, or severe impairments but mild symptoms.
Which is the greater component, if either, the score itself does not reflect. The
GAF score may reflect impaired functioning of some sort—or it may not. The
DSM considers that an individual’s functioning may not be affected by even
significant symptoms. As the DSM notes at 33 (emphasis added),
For example, the GAF rating for an individual who is a significant
danger to self but is otherwise functioning well would be below 20.
Similarly, the GAF rating for an individual with minimal
psychological symptomatology but significant impairment in
functioning (e.g., an individual whose excessive preoccupation with
substance use has resulted in loss of job and friends but no other
psychopathology) would be 40 or lower.
The reliability of the GAF score in the Social Security context is further
reduced because the impairment component has no direct correlation to
occupational impairments. It is subdivided into sub-components of psychological,
social, and occupational impairments. DSM IV at 30. The score does not identify
the weight of the occupational sub-component, if any. It may be based primarily
on psychological or social impairments that do not create occupational
impairments.
 The DSM gives examples of the sorts of factors that may be found for GAF
scores within certain ranges, using adjectives such as Aserious,@ Asevere,@ and
Amoderate.@ 11 However, those adjectives do not necessarily refer to an
occupational impairment, if they even refer to an impairment -- rather than
symptoms -- at all. All of the examples are in the disjunctive. And the existence
of the disjunctive is consistently emphasized. For example, at the first of the four
steps in assessing a GAF score, the practitioner must consider each of the 10-point
ranges: “Starting at the top level, evaluate each range by asking “is either the
1 1A GAF score of 1 to 10 may denote a “persistent danger of severely hurting self or
others…OR persistent inability to maintain minimal personal hygiene OR serious suicidal
act with clear expectation of death.” DSM-IV at 34 (emphasis in original). A GAF score
of 11 to 20 may denote “some danger of hurting self or others…OR occasionally fails to
maintain minimal personal hygiene…OR gross impairment in communication.” Id.
(emphasis in original). GAF score of 21 to 30 may note a “behavior [that] is
considerably influenced by delusions or hallucinations OR [a] serious impairment in
communication or judgment…OR inability to function in almost all areas (e.g., stays in
bed all day; no job, home, or friends). Id. (emphasis in original). A GAF score between
31 and 40 may denote “some impairment in reality testing or communication… OR
major impairment in several areas, such as work or school, family relations, judgment,
thinking, or mood.) Id. (emphasis in original on capitalized “OR”). A GAF score
between 41 and 50 may denote “serious symptoms…OR [a] serious impairment in
social, occupational, or school functioning. Id. (emphasis in original). A GAF score
between 51 and 60 may denote “moderate symptoms OR moderate difficulty in social,
occupational, or school functioning.” Id. (emphasis in original on capitalized “OR”). A
GAF score between 61 and 70 may denote “some mild symptoms…OR some difficulty in
social, occupational, or school functioning…but generally functioning pretty well, has
some meaningful interpersonal relationships.” Id. (emphasis in original). At 71 and
above, the disjunctives virtually disappear. At 71 to 80 the score may denote that “if
symptoms are present, they are transient and expectable reactions to psychosocial stressors
[and]…no more than slight impairment in social, occupational, or school functioning.”
Id. At 81 to 90, the score indicates “absent or minimal symptoms…, good functioning all
areas, interested and involved in a wide range of activities, socially effective, generally
satisfied with life, no more than everyday problems or concerns….” Id. At 91 to 100
there is “superior functioning an 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.
No symptoms.” Id.
individual’s symptom severity OR level of functioning worse than what is
indicated in the range description?” (Emphasis on “either” and “OR” in original).
At the second step, the practitioner continues moving down the scale until reaching
a range “that best reaches the individual’s symptom severity OR the level of
functioning is reached, whichever is worse.” Id. (emphasis on “OR” and
“whichever is worse” in original). The third step is a confirmation of the first two,
and then at Step 4, the practitioner considers where to place the patient within the
10-point range. The example given in the DSM is one of a patient who does not
have functional limitations yet whose symptoms result in a GAF score of 31 to 40:
“For example, consider an individual who hears voices that do
not influence his behavior (e.g., someone with long-standing
schizophrenia who accepts his hallucinations as part of his
illness.) If the voices occur relatively infrequently (once a
week or less), a rating of 39 or 50 might be most important. In
contrast, if the individual hears voices almost continuously, a
rating of 31 or 32 would be more appropriate.”
Id. The emphatic disjunction between symptoms and functional limitations thus
highlights the unreliability of the GAF score as an assessment of functioning. This
inherent unreliability – in the context of ascertaining functional limitations – is
further illustrated in the detailed assessments made within each 10-point range.
For example, if a GAF score falls within the range of 41 through 50,
generally described as denoting a Aserious@ mental status, that score may denote
serious Asymptoms@ relevant to the first component -- severity of the
psychological symptoms -- such as Asuicidal ideation or severe obsessional
rituals.@ See DSM-IV at 34 (emphasis added). Or it may reflect serious
Aimpairments.@ Which impairment or combination of impairments is serious the
score does not reflect. For example, a GAF score in the range of 41 to 50, if the
impairment component is higher than the symptom component, reflects a Aserious
impairment@ of some sort. However, the category of impairments is in the
disjunctive as are the examples of impairments: Asocial [or], occupational, or
school functioning, such as the absence of friends or the inability to keep a job. Id.
(emphasis added). Thus, the GAF score might have been assigned based in
significant part on occupational factors and therefore perhaps relevant to the
benefits application: or it might not.
In sum, a GAF score is an undifferentiated amalgam of conclusions
regarding mental health, which may or may not reflect a medical source=s
observation of an occupational impairment. It is a Ablack box@ potentially
containing some or all of the factors of which a GAF score may be comprised, in
unknown proportions to one another. One can only speculate as to the contents.

Having no direct correlation to the severity of any occupational impairment,

an unexplained GAF score thus Adoes not have a direct correlation to the severity
requirements in [the] mental disorders listings.@ Revised Medical Criteria for
Evaluating Mental Disorders and Traumatic Brain Injury, 65 Fed. Reg. 50746,
50764-65 (August 21, 2000); see also 42 U.S.C. ' 423(d) (2); 20 C.F.R. '' 416.905,
416.912 (2007). It does not establish or quantify a limitation in functioning
caused solely by a mental disorder as required by the Listings. See e.g., Listing '
112.00A.
In sum, a GAF score is not a medical opinion within the meaning of the
regulations. A medical opinion is a statement from A[an] acceptable medical
source[] that reflect[s] judgments about the nature and severity of [Plaintiff=s]
impairment(s), including [Plaintiff=s] symptoms, diagnosis, and prognosis, what
[Plaintiff] can still do despite impairment(s), and [Plaintiff=s] physical and mental
restrictions.@ 20 C.F.R. ' 416.927(a) (2); see also 20 C.F.R. ' 416.945(a)(3)
(evidence used to assess residual functional capacity). A GAF score does not
delineate functional limitations or occupational impairments, it does not inter alia,
describe how Asymptoms translate into specific functional deficits which preclude
work activity.@ See e.g., Morgan v. Commissioner of Soc. Sec., 169 F.3d 595,
601 (9thCir. 1999)(identification of Aaffective instability, intense anger, daily
suicidal thoughts, chronic feelings of emptiness@ insufficient given lack of
explanation of Ahow@ those characteristics precluded work activity (emphasis in
original)).
Given its nature, then, while a GAF score Amay be of considerable help to
the ALJ in formulating the RFC. . . . it is not essential to the RFC=s accuracy.@
Howard v. Comm=r of Social Sec., 276 F.3d 235, 241 (6th Cir. 2002)(emphasis
added); Baker v. Astrue, Cv 08-3199 MLG, 2009 Westlaw 279085 (C.D.Ca. Feb.
9, 2009) Gideon v. Astrue, EDCV 08 0191 AN (C.D. Cal. Feb. 3, 2009).
0Craghead, EDCV 07-1503 AGR, 2008 Westlaw 5122280 (C.D. Cal. Dec. 5,
2008); Trinchere v. Astrue, 2008 WL 4395283, * 6 (C.D.Cal. Sept. 3, 2008). If it
is not essential, it is not material, and the ALJ therefore need not have addressed it.

Even if the ALJ were to have addressed a GAF score, a GAF score, any
more than a mere diagnosis, would not affect the RFC. Any error in addressing the
score was therefore harmless --Anonprejudicial to the claimant or irrelevant to the
ALJ=s ultimate disability conclusion.@ Stout v. Comm=r. Soc. Sec. Admin.,
454 F. 3d 1050, 1055 (9th Cir. 2006) (citing Burch v. Barnhart, 400 F. 3d 676, 679
(9th Cir. 2005)); Robbins v. Soc. Sec. Admin., 466 F. 3d 880, 885 (9th Cir. 2006).
Of course an error is not harmless if the ALJ fails to properly discuss significant
evidence and the court can Aconfidently conclude@ that a reasonable ALJ, Awhen
fully crediting the evidence, could have reached a different disability
determination.@ Attia v. Astrue, 2007 WL 2802006, at * 29 (E.D. Cal. Sept. 24,
2007) (citing Stout). However, a GAF score does not alone constitute evidence
that may affect the outcome of a disability determination.
In sum, 0a GAF score “is distinguishable from a medical opinion and may
reflect severe symptoms that do not necessarily translate into work-related
impairments or a significant impairment that does not have a correspondingly
restrictive effect on occupational functioning. The Commissioner has explicitly
disclaimed an intent to endorse use of the GAF scale and while it may be “of
considerable help” to the ALJ in formulating the RFC it is “not essential to the
RFC’s accuracy.” The ALJ’s failure to reference a GAF score “standing alone”
does not vitiate the accuracy of the decision. 0Bilsbarrow v. Astrue, EDCV 07-
0569 AJW (C. D. Cal. April 15, 2008).
0A GAF score standing alone cannot affect an RFC finding. It “does not directly
correlate with a disability determination under the Social Security Act, functioning
as more of a clinical benchmark or descriptor than an opinion as to a patient’s
limitations caused by a specific impairment. . . . It “sheds no light on whether
Plaintiff’s medically determinable illness prevents him from working. In any
event, the ALJ was not required to mention [the doctor’s] GAF score . . . .”
0Baker, CV 08 3199 MLG, 2009 Westlaw 279085 (C.D. Ca. Feb. 9, 2009).