Axis V: Global Assessment of Functioning

 

Axis V is for reporting the clinician's judgment of the individual's overall level of functioning. This information is useful in planning treatment and measuring its im­pact, and in predicting outcome.

 

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 measure. The GAF 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 a 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. For example, the first part of the range 41-50 de­scribes "serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting)" and the second part includes "any serious impairment in social, occupa­tional, or school functioning (e.g., no friends, unable to keep a job)." It should be noted that in situations where the individual's symptom severity and level of functioning are discordant, the final GAF rating always reflects the worse of the two. 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.

 

In most instances, ratings on the GAF Scale should be for the current period (i.e., the level of functioning at the time of the evaluation) because ratings of current func­tioning will generally reflect the need for treatment or care. In order to account for day to day variability in functioning, the GAF rating for the "current period" is some­times operationalized as the lowest level of functioning for the past week. In some settings, it may be useful to note the GAF Scale rating both at time of admission and at time of discharge. The GAF Scale may also be rated for other time periods (e.g., the :Highest level of functioning for at least a few months during the past year). The GAF scale is reported on Axis V as follows: "GAF followed by the GAF rating from 0 to 100, followed by the time period reflected by the rating in parentheses-for example, (current)," "(highest level in past year)," "(at discharge)." (See examples on p. 35.)

 

In order to ensure that no elements of 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 range by asking "is 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. If it is, the appropriate range has been reached (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. For example, consider an individual who hears voices that do not influence a 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 - less), a rating of 39 or 40 might be most appropriate. In contrast, if the individual hears voices almost continuously, a rating of 31 or 32 would be more appropriate.

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. For this purpose, a proposed Social and Occupational Functioning . Assessment Scale (SOFAS) (see p. 817) is included in Appendix B. Two additional pro­posed scales that may be useful in some settings-the Global Assessment of Rela­tional Functioning (GARF) Scale (see p. 814) and the Defensive Functioning Scale (see page 807)-are also included in Appendix B.

 

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

 

Code

Description

91 to 100

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. No symptoms.

81 to 90

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).

71 to 80

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

61 to 70

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 interper­sonal relationships.

51 to 60

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).

41 to 50

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).

31 to 40

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).

21 to 30

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).

11 to 20

Some danger of hurting self or others (e.g., suicide attempts without dear 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).

1 to 10

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.

0

Inadequate information.

 

 

 

The rating of overall psychological functioning on a scale of 0-100 was operationalized by Luborsky in the Health-Sickness Rating Scale (Luborsky L: "Clinicians' Judgments of Mental Health." Archives of General Psychiatry 7:407-417, 1962). Spitzer and colleagues developed a revision of the Health­/Sickness Rating Scale called the Global Assessment Scale (GAS) (Endicott J, Spitzer RL, Fleiss JL, Cohen J: "The Global Assessment Scale: A Procedure for Measuring Overall Severity of Psychiatric Distur­bance." Archives of General Psychiatry 33:766-771, 1976). A modified version of the GAS was includ­ed in DSM-III-R as the Global Assessment of Functioning (GAF) Scale.