The Global Assessment of Functioning 1is a graded scale expressed numerically from 0 to 100 to provide a rating of the social, occupational and psychological functioning of adults. It is used by health care professionals to assess how well the subject is meeting problems-in-living. The score is frequently expressed as a range. The lower the score, the more severe the condition is.
The score is defined in the Diagnostic and Statistical Manual of Mental Disorders previously known as DSM-IV and DSM-V as of May 2013. This was the first major revision in nearly twenty years. It is referred to colloquially as the “psychiatric bible”. The manual is published by the American Psychiatric Association (“APA”) and lists all mental health disorders and their causes. There is no public accountability to the APA and its determination of the contents of the DSM.
It has been frequently used in litigation dealing with insurance claims.
The method of scoring a psychiatric disorder requires five out of six symptoms for a majority of the time, which are to be evidenced for a period of at least fourteen days. The patient who records five such points is given a label, while one who receives four does not.
Generally speaking, only three percent of DSM disorders have any known biological causes. The root causes of the remaining disorders are not known. Psychiatric disorders are, in fact, based on subjective judgments. Included in this category are labels such as depression, anxiety, attention deficit hyperactivity disorder and all personality disorders.
The theory that chemical imbalances cause mental illness is unproven.
The DSM, itself, has not been without controversy. The first version, released in 1952, listed homosexuality as a sociopathic personality disturbance. In 1968, DSM II was released which reclassified homosexuality as a sexual deviancy. In 1973, it was decided by the APA to remove homosexuality from its next iteration in DSM IV. In 1974, a referendum was called which resulted in approximately 40% of the membership of APA voting to re-enlist homosexuality as psychiatric disorder, short of the required majority.
Similarly in DSM IV, the definition of a major depressive disorder was qualified by an exception for those suffering from the death of a loved one, known as the “bereavement exclusion”. That raised other comparable situational examples, such as the emotional suffering experienced due to life events of divorce or termination of employment, neither of which was given such an exclusion. In DSM V, the bereavement exclusion was eliminated.
In the prelude to DSM V, panels of experts debated as to whether sexual addiction should be added as a mental illness. The conclusion was that there was insufficient evidence to show that individuals can become addicted to sex in the same way as with alcohol or drugs.
This history is reflective of the concept that the development of the manual is clearly not a scientific process. As stated by a writer and psychotherapist: 2
The most curious aspect of the status quo in psychiatry, though, is how a scientific-looking manual put out by a small organization with no public accountability has come to be viewed with such reverence. Not for nothing is the DSM known as the “psychiatric bible”. Perhaps its bullet-pointed diagnoses do satisfy a religious need, the old existential ache for reassurance that “even the hairs of your head are all counted” and there’s no reason to be afraid.
In April of 2013, Thomas Insel, 3 stated that the DSM was “at best, a dictionary” and that “symptoms alone rarely indicate the best choice of treatment”. He also wrote “patients with mental disorders deserve better”. Insel also stated that his Institute will no longer pay attention to the DSM when it conducts research and will instead focus on neuroscience. He stated:
Mental disorders are biological disorders involving brain circuits. The Institute will focus its research on identifying which of the brain’s circuits are responsible for thoughts, emotions and behaviours, and what causes them to go haywire.
The DSM and resulting GAF score has been historically used by mental health professionals to allow interested third parties, such as insurers, to comprehend the severity of the needs of the patient. It has tended to be treated reverentially by courts. The reality is that the DSM manual itself is suspect and the scoring process is very subjective.
The reviewer depends virtually entirely upon the symptoms expressed by the patient for the resultant score. The reverence which has attached to the numerical GAF score, accordingly, may be very much disputed.
The DSM-IV uses a “multi-axial” or multi-dimensional approach to the diagnosis as many factors in a person’s life may impact their mental health. The five axis are as follows:
Axis I Clinical Syndromes
This refers to the diagnosis, such as depression, anxiety disorder, dementia, etc.
Axis II Development Disorders and Personality Disorders
Development disorders include autism and mental retardation, which usually are first noticed in childhood.
Personality disorders are clinical syndromes which show more long lasting symptoms and reflect the individual’s manner of interacting with the world. These include paranoid, antisocial, obsessive compulsive disorder and borderline personality disorders.
Axis III Physical Conditions
Often physical factors may play a role in the development, continuance or exacerbation of Axis I and II disorders. Examples of such a physical conditions would include a brain injury, heart disease or diabetes.
Axis IV Severity of Psychological Stressors
Circumstances in a person’s life include life stressors such as death of loved one, unemployment, starting a new career, a new school, divorce or marriage can impact the disorders set out in
Axis I or Axis II. Such events are listed and rated in this axis.
Axis V Highest Level of Functioning
On this axis, the health care professional rates the patient’s level of functioning both at the present time and the highest level within the prior year. This is intended to demonstrate how the above four axes affect the patient and what type of changes are to be expected.
Appendix B shows the scores from the DSM IV- TR.
Dr. Bruce Leckart expressed the same view, namely, that while the determination of the GAF score, while appearing to be numerically quantifiable, it is, in fact, highly subjective and has been the subject of much controversy as to its reliability and validity, in his text. 4 5
The DSM V was approved as of May 18, 2013 which no longer uses the five axes as set out above. The new manual removes the prior multi-axial system in favor of non-axial documentation of diagnosis, which will combine the former Axes I, II, and III with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).
The Ontario Superior Court 6 cautioned against placing too much emphasis on the GAF in a case in which the plaintiff claimed disability benefits based on a psychiatric illness. The trial judge was of the view that the GAF score cannot be considered conclusive evidence.
The Alberta Supreme Court 7 came to the conclusion in reviewing the above passage that the GAF score may be given some weight, but its conclusion is not to be regarded as definitive of the issue.