The Global Assessment of Functioning (GAF) Scale

Every once in a while I am faced with paperwork concerning my mental health. This has happened with insurance companies, state programs I have applied for, and even the medical records I have requested and snooped through (hey, I should be allowed to know what they’re saying about me, right?). Upon looking at this paperwork, I am generally surprised by what I find -not due to the content (though sometimes I am) but because of the paperwork itself. The way the questions are phrased and answered, the way sections are broken up, entire ranking scales I knew nothing about… obviously there is a system that I have been completely unaware of. I mean, heck, I’m no doctor, I’ve never been trained on what all of this means, and if I didn’t go back and read the paperwork attached to my diagnosis I would never have even known such scales existed.

I thought I would take a little time today to talk about one scale which I have seen several times in various situations, but never really knew much about until recently. You know me, I am all kinds of interested in different ways to quantify my bipolar experience, so I found this scale particularly interesting.

It is called the Global Assessment of Functioning (GAF) Scale. I guess Global suggests it is used throughout the world, and it came to my attention because I noticed this scale popping up on several of the items I have rifled through in the last five years.

So what is the Global Assessment of Functioning Scale?

The Washington Institute On-Line Training and Assessment contracted by the Washington State Mental Health Division calls the GAF scale:

A 100-point tool rating overall psychological, social and occupational functioning of people over 18 years of age and older. It excludes physical and environmental impairment.

Which means this ranking scale is a tool used to rate functioning (not symptoms) in three areas (psychological, social, and occupational).

Since the GAF scale is used to rate functioning (and not symptoms) your score could potentially be constantly changing (that is, if you’ve got bipolar disorder, for example, and have been having symptoms intense enough to change your level of functioning). Generally, the closer you are to 100, the better you are functioning. The scale is also used to quantify disabled-ness, as the closer you are to zero, the more disabled you are considered.

The GAF scale is broken down like this:

91-100
Superior functioning in a wide rage of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms.
90-81
Absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range or activities, socially effective, generally satisfied with life, no more than everyday problems or concerns.
80-71
If symptoms are present they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning
70-61
Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.
60-51
Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning.
50-41
Serious symptoms OR any serious impairment in social, occupational, or school functioning.
40-31
Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.
30-21
Behavior is considered influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas.
20-11
Some danger or hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication.
10-1
Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death.

Your doctor or clinician might be asked to rate you with this scale in situations of requests by your insurance, if you are going through an intake at a hospital, if you are applying for state or federal disability programs, and the like.

I recently had an insurance agency ask my psychiatrist to give the highest GAF score he would attribute to me for the last year, and that was how my curiosity became piqued by this scale. I had also seen this in passing on medical records from when I was hospitalized. They gave a GAF score for when I entered the hospital, as well as what my score was when I left. Obviously at that point they want to see some kind of improvement on your part in the scale.

The GAF scale is found in the Diagnostic and Statistical Manual – IV TR (or just DSM as many of us lovingly refer to it) in the section on “multi-axial assessments”. You can also find the whole scale online by just googling it, or by following the link here for the Washington Institute On-Line Training and Assessment.

I wondered for a bit if this rating scale is generally supported globally, and I did find an article in the British Journal of Psychiatry about a study done to test the validity of the GAF scale in 1995 (which you can find here). They concluded;

GAF proved to be a reliable and, within the limits of the indicators used, a valid measure of psychiatric disturbance in our sample of the severely mentally ill.

There are other versions of the GAF scale that have been modified, but apparently don’t stack up quite as well as this original scale.

In conclusion, this was really just something that I find interesting personally, but I also think it is important to understand things like medical records and paperwork that has been filled out by your doctor. I don’t think knowing about what tools our doctors are using is important because we should interfere with their work, but because understanding how our doctors operate can help us maintain a better relationship and get the best care possible.

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