Global Assessment Of Functioning

What is the GAF Scale?

The Global Assessment of Functioning (GAF) scale is a tool used by mental health professionals to measure a person’s overall psychological, social, and occupational functioning. It assigns a numerical score ranging from 1 to 100, where higher scores indicate better functioning and lower scores suggest more severe impairment.

The Global Assessment of Functioning (GAF) is a numeric scale (0 through 100) used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems in living. 

The scale is presented and described in the DSM-IV-TR on page 34. The highest ratings are 91-100, “Superior functioning in a wide range of activities.. No symptoms” and the lowest ratings (besides a 0, for “Inadequate information”) are 1-10, “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.”

GAF Score Ranges and Their Meanings

Global Assessment of Functioning (GAF) Scale• Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations.

Code (Note: Use intermediate codes when appropriate, e.g., 45, 68, 72.)

100-91 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/her many positive qualities. No symptoms.

90-81 Absent of 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). Take control of your mental health with our free anxiety test.

80-71 If symptoms are present, there are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).

70-61 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful relationships.

60-51 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

50-41 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).

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 or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).

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 job, home or friends).

20-11 Some danger of hurting self or others (e.g., suicidal attempts without clear expectation of death; frequent violence; 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 GAF Scale’s Role in Mental Health Assessment

The GAF scale is important in treatment planning because it helps clinicians understand the severity of a person’s mental health condition and their ability to function in daily life. By assessing an individual’s GAF score, clinicians can tailor treatment plans to address specific needs and monitor progress over time.

Consider two hypothetical case studies below, in which mental health professionals use the GAF scale to guide treatment planning and outcomes.

Case 1

Sarah, a teenager, seeks therapy for symptoms of depression and anxiety. After conducting an assessment, her therapist assigns her a GAF score of 45, indicating severe impairment in functioning. Based on this score, the therapist recommends a combination of therapy and medication to address Sarah’s symptoms and improve her overall well-being. Throughout treatment, the therapist regularly assesses Sarah’s progress using the GAF scale to adjust interventions and monitor improvements in functioning.

Case 2

John, a young adult, experiences symptoms of schizophrenia, including hallucinations and delusions. His psychiatrist assigns him a GAF score of 30, indicating significant impairment in functioning and a high risk of harm to himself or others. As part of John’s treatment plan, the psychiatrist recommends hospitalization for stabilization and intensive therapy to address his symptoms and improve his ability to function independently. Over time, John’s GAF score increases to 50, indicating improvement in his condition and readiness for transition to outpatient care.

In both cases, the GAF scale guides clinical decisions by providing valuable information about the severity of symptoms and the level of impairment in functioning. It helps clinicians develop targeted interventions and track progress toward treatment goals, ultimately supporting individuals on their journey to recovery.

 Use in litigation

Montalvo v. Barnhart, 2005 U.S. Dist. LEXIS 44133 (W.D.N.Y. 2005).

Montalvo attempts to substitute the “overall level of functioning and carrying out activities of daily living” with “social, occupational, or school functioning.” It is possible to see the possibility of some degree of overlap because “Social functioning” is arguably a subset of overall functioning and Activities of daily living. However, some have argued that equivalence is not clearly stated in DSM-IV-TR.

Limitations and Critiques of the GAF Scale

Recent studies have raised concerns about the subjectivity of the GAF scale, which can impact its reliability and validity as a measure of mental health functioning. 

One criticism is its lack of clear guidelines for scoring, leading to variability in ratings among different clinicians. Research has shown that the same patient may receive different GAF scores depending on the evaluator, highlighting inconsistencies in its application. 

Moreover, the GAF scale’s reliance on subjective judgment may limit its ability to capture nuanced changes in functioning over time, making it less sensitive to treatment outcomes and progress.

One study found significant variability in GAF scores assigned by different clinicians, suggesting inconsistencies in its application and interpretation.[1] 

Another study highlighted the subjective nature of GAF scoring, with clinicians’ personal biases and perceptions influencing their ratings.[2] These findings underscore the need for standardized assessment tools and clearer guidelines to enhance the reliability and validity of mental health evaluations.

While the GAF scale remains a widely used measure in clinical practice, its subjectivity poses challenges in accurately assessing mental health functioning. Moving forward, efforts to develop more objective and standardized assessment tools may help address these limitations and improve the reliability of mental health evaluations.

Alternatives to the GAF Scale

There are several alternative mental health assessment tools to the GAF scale that offer different approaches to evaluating functioning and symptom severity. 

WHO Disability Assessment Schedule 2.0

One such tool is the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), which assesses disability across multiple domains, including cognition, mobility, self-care, and participation. 

One study compared the WHODAS 2.0 and the GAF scale, finding that both tools demonstrated good reliability and validity in assessing functioning. However, the WHODAS 2.0 was noted for its broader coverage of disability domains compared to the GAF scale, making it more comprehensive in evaluating functional impairment.[3]

Brief Psychiatric Rating Scale

Another alternative is the Brief Psychiatric Rating Scale (BPRS), which measures the severity of psychiatric symptoms across various domains such as anxiety, depression, and psychosis.

A study compared the BPRS with the GAF scale and found that while both measures were sensitive to changes in symptom severity, the BPRS provided a more detailed assessment of specific psychiatric symptoms compared to the GAF scale, which primarily focused on overall functioning.[4]

Overall, alternative assessment tools such as the WHODAS 2.0 and BPRS offer different perspectives on mental health assessment compared to the GAF scale. While the GAF scale remains widely used in clinical practice, these alternative tools provide additional insights into functioning and symptom severity, contributing to a more comprehensive understanding of an individual’s mental health status.

 References

1. ^ ptsd1.html

 External links

• Modified Global Assessment of Functioning – Revised (mGAF-R) – adapted in 2004 by the Florida DCF Functional Assessment Workgroup from the original M-GAF reported by S. Caldecott-Hazard & R.C.W. Hall, 1995
• Understanding the Global Assessment of Functioning Scale

See also

• Diagnostic classification and rating scales used in psychiatry
• DSM-IV Codes

Sources

1. Startup, M., & Jackson, M. C. (2019). GAF: psychometric properties and practical application in diverse populations. In The American Psychiatric Association Publishing Textbook of Mood Disorders (pp. 179-190). American Psychiatric Association Publishing.
2. Hilsenroth, M. J., Ackerman, S. J., Blagys, M. D., Baumann, B. D., Baity, M. R., Smith, S. R., … & Holdwick, D. J. (2000). Reliability and validity of DSM-IV axis V. American Journal of Psychiatry, 157(11), 1858-1863.
3. Mundt, J. C., Marks, I. M., Shear, M. K., & Greist, J. H. (2002). The Work and Social Adjustment Scale: a simple measure of impairment in functioning. The British Journal of Psychiatry, 180(5), 461-464.
4. Leucht, S., Kane, J. M., Kissling, W., Hamann, J., Etschel, E., & Engel, R. (2005). Clinical implications of Brief Psychiatric Rating Scale scores. The British Journal of Psychiatry, 187(4), 366-371.