Camille C.

Fernandez
MS Clinical Psychology

Article Review:
DSM-IV-TR: Axis V: Global Assessment of Functioning (GAF)

Article Summary
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:
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.

GAF Scale

The furthest predecessor of the Global assessment of functioning Scale (GAF) 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 reporting of overall functioning on Axis V can be done using the Global
Assessment of Functioning (GAF) Scale. The GAF Scale may be particularly useful in
tracking the clinical progress of individuals in global terms, using a single measures. The
GAP scale is to be rated with respect only to psychological, social, and occupational
functioning, the instructions specify, “Do not include impairment in functioning due to
physical (or environmental) limitations.”

The GAF scale is divided into 10 ranges of functioning. Making GAF rating
involves picking a single value that best reflects the individual’s overall level of
functioning. The description of each 10-point range in the GAF scale has two components;
the first part covers symptom severity, and the second part covers functioning. The GAF
rating is within a particular decile if either the symptom severity or the level of functioning
falls within the range.

In order to ensure the GAF Scale are overlooked when a GAF rating is being made,
the following method for determining a GAF rating may be applied:
 STEP 1: Starting at the top level, evaluate each rang by asking, “Either the
individual’s symptom severity or level of functioning worse than what is indicated in the
range description?”
STEP 2: keep moving down the scale until the range that best matches the
individual’s symptom severity or the level of functioning is reached, whichever is worse.
STEP 3: Look at the next lower range as a double check against having stopped
prematurely. This range should be too severe on both symptom severity and level of
functioning (continue with STEP 4). If not, go back to STEP 2 and continue moving down
the scale.
STEP 4: To determine the specific GAF rating within the selected 10-point range,
consider whether the individual is functioning at the higher or lower end of the 10-point
range.

Other Related GAF Scales

The modified Global Assessment of Functioning (mGAF) scale provides a more

detailed criteria and scoring system than the original GAF. The mGAF can be used instead
of the GAF if approved by the RCC. Some state outcome forms require the use of the
mGAF. The mGAF rates the lowest possible score for each client.

The Florida Department of Children and Families made modifications to the mGAF
in 2005, so that that the mGAF could be used to measure the level of functioning for
persons in “med only” services. Specifically, the descriptive statements within the ten point
intervals were rephrased to improve the face validity and readability of the items. DCF
gives the following instructions for completion of the mGAF-R:

The Children’s Global Assessment Scale was adapted for use with children. It is
based on the GAF scale. Scoring for the CGAS ranges from 1, in need of constant
supervision, to 100, superior functioning. To assign a CGAS rating, rate the child’s most
impaired level of functioning. Within each category there is a 10 point range. Choose the
number that is the most descriptive of the overall functioning of the individual.

Article Critique Review

Points of Agreement
The GAF can be reliable, valid, and sensitive to change over time. Nevertheless,
its limitations have been widely acknowledged. A rater's training and performance are
fundamental to the GAF's reliability, and appropriate training improves both reliability and
validity.

Points of Disagreement
 The validity of assigned GAF scores often correlates more highly with the severity
of symptoms than with levels of impairment, particularly when severity of symptoms and
degree of functional impairment are not congruent. The GAF's conflation of symptom
severity, including dangerousness to self or others, and functional impairment into a single
global assessment score decreases the construct validity of the GAF and is one of its major
disadvantages.

Points for Improvement

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.

Analysis and Conclusion

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.
GAF levels are commonly used by the Veterans Benefits Administration of
the United States Department of Veterans Affairs in determining the appropriate level of
disability compensation to be paid to veterans who suffer from service connected
psychiatric disorders. The emphasis by the Veterans Administration on using the GAF
score has, however, decreased in recent years.
However, in spite of the deficiencies of the GAF, numerous researchers have assess
and generate more research about the reliability and validity of the GAF.
One case a group of researchers who examined the reliability, convergent and
discriminant validity of the DSM-IV axis V (GAF) Scale the Global Assessment of
Relational Functioning Scale and the Social and Occupational Functioning Assessment
Scale demonstrated that all exhibited very high levels of inter-rater reliability Factor
analysis of their study revealed that the Global Assessment of Relational Functioning Scale
and the Social and Occupational Functioning Assessment Scale are each more related to
the Global Assessment of Functioning Scale individually than they are to each other. The
Global Assessment of Functioning Scale was significantly related to concurrent patient
responses on the SCL-90-R global severity index. The Social and Occupational
Functioning Assessment Scale was significantly related to concurrent patient responses on
the SCL-90-R global severity index and to a greater degree with both the Social Adjustment
Scale global score and the Inventory of Interpersonal Problems total score. The researchers
also conclude that the three axis V scales can be scored reliably and that it can be used in
treatment research. (Hilsenroth, Ackerman, Blagys, Bauman, Baity, Smith, Price,
Heindselman, Mount and Holdwick, 2000).
Moreover, a study by O. Bodlund, G. Kullgren, L. Ekselius, E. Lindström, L. von
Knorring conclusively ilustrated the GAF self-report turned out to be a valid and reliable
one-dimensional instrument measuring psychological, social and occupational functioning.
The researchers also concluded that the GAF is easy to handle, and with a self-report
version as a complement, Axis V could be more frequently used in future clinical practice
and research.
Therefore, it still important to consider the updated source for determining the level
of functioning of the client. There are still clinician who used DSM-IV as a guide to know
their client’s level of functioning and some use the World Health Organization Disability
Assessment Schedule (WHODAS) in DSM-V.
References

Global Assessment of Functioning (GAF) Scale Retrieved November 19, 2018 from
http://www.albany.edu/counseling_center/docs/GAF.pdf

Psychiatry (2006) Revising axis V for DSM-IV: a review of measures of social

functioning Retrieved November 19, 2018 from
http://ajp.psychiatryonline.org/doi/abs/10.1176/aj p.149.9.1148

Richard H (1995). Global Assessment of Functioning: A Modified Scale Retrieved

November 19, 2018 from http://www.sciencedirect.com/sci
ence/article/pii/S0033318295716668

Senior Homes (2016). Understanding the Global Assessment of Functioning Scale

Retrieved November 19, 2018 from https://www.seniorhomes.com/p/understanding-the-
global-assessment-of-functioning-scale/#history