The Global Assessment of Functioning is a numeric scale used by mental health clinicians and physicians to rate subjectively the social, occupational, and psychological functioning of an individual, e.g., how well one is meeting various problems in living. Scores range from 100 to 1. The scale was included in DSM-IV, but replaced in DSM-5 with the WHODAS, a survey or interview with detailed items. The WHODAS is supposed to be more detailed and objective than a single global impression. The main advantage of the GAF would be its brevity.
Development and exclusion from DSM-5
Interest in a quantifiable global rating of functioning dates back to as early as 1962 with the publication of the Health-Sickness Rating Scale by Luborsky et al. in the paper "Clinicians' Judgements of Mental Health". This was subsequently revised in 1976 as the Global Assessment Scale in the paper "The Global Assessment Scale:Procedure for Measuring Overall Severity of Psychiatric Disturbance" by Endicott et al. The rating scale was further modified and published as the Global Assessment of Functioning Scale in the DSM-III-R and DSM-IV. Some versions of the scale stopped at 90 as the maximum score, and others extended to 100. Because the scale was most often used with people seeking health services, it would be rare to have scores over 90, as they would indicate not just a lack of symptoms, but also "superior functioning." The related SOFAS scale was initially described in a paper by Goldman et al. in 1992 in the paper "Revising Axis V for DSM-IV: A review of measures of social functioning." The DSM-IV included the SOFAS within the section "Criteria Sets and Axes Provided for Further Study." The SOFAS scale is similar to the GAF, but it only looks at social and occupational functioning rather than also considering symptom severity. DSM-5 removed the multiaxial system, including Axis V disability and functioning; and the DSM-5 Task Force recommended the GAF be replaced by the WHO Disability Assessment Schedule in an effort to increase the reliability of scores.
Scale
Use in litigation
Montalvo attempts to substitute "social, occupational, or school functioning" for "overall level of functioning and carrying out activities of daily living". It is possible to see the recourse of some degree of overlap because "social functioning" is arguably a subset of overall functioning and activities of daily living. However, it is arguable whether equivalence is clearly stated in DSM-IV-TR. GAF scores were commonly used by the Veterans Benefits Administration to help determine disability ratings for service-connected psychiatric disorders. The probative value given to GAF scores diminished since the 2013 publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, which eliminated GAF scores from the Manual's nosology because GAF scores do not demonstrate good reliability or construct validity. On February 23, 2018, the United States Court of Appeals for Veterans Claims, issued an opinion in Golden v. Shulkin. ruling that, except for some older cases on appeal, the Board of Veterans Appeals "... should not use at all when assigning a psychiatric rating in cases where the DSM-5 applies." In disability cases before the Social Security Administration, the agency determines if the GAF is consistent with the narrative report and it is addressed as one technique for capturing the "complexity of clinical situations." The agency noted the GAF is just one tool used by clinicians to develop the clinical picture. It cannot be used in isolation from the rest of the evidence to make a disability decision. The Commissioner of Social Security has acknowledged that the GAF system has some problems, but found that, if provided by an "acceptable medical source, a GAF is a medical opinion as defined in" the Regulations, and must be considered with all of the relevant evidence, but can be given "controlling weight" if well supported and not inconsistent with the other evidence.
