Global Assessment of Functioning (GAF) Scale (DSM - IV Axis V)

Note: This e!sion of the GAF scale is inten"e" fo! aca"emic use onl#$ Although it is base" on
the clinical scale %!esente" in the DSM - IV& this summa!# lac's the "etail an" s%ecificit# of the
o!iginal "ocument$ The com%lete GAF scale on %age () of the DSM - IV shoul" be consulte" fo!
clinical use$
*o"e Desc!i%tion of Functioning
+, - ,-- Person has no %!oblems OR has superior functioning in several areas
OR is admired and sought after by others due to positive qualities
., - +- Person has fe/ o! no s#m%toms. Good functioning in several areas. No
more than "everyday" problems or concerns.
0, - .- Person has symptoms/problems, but they are tem%o!a!#& ex%ectable
!eactions to st!esso!s. here is no more than slight impairment in any
area of psychological functioning.
1, - 0- Mil" s#m%toms in one a!ea OR difficulty in one of the follo!ing" social,
occupational, or school functioning. #$, the person is generally
functioning pretty !ell and has some meaningful interpersonal
relationships.
2, - 1- Mo"e!ate s#m%toms OR moderate difficulty in one of the follo!ing"
social, occupational, or school functioning.
3, - 2- Se!ious s#m%toms OR serious impairment in one of the follo!ing"
social, occupational, or school functioning.
(, - 3- Some im%ai!ment in !ealit# testing OR impairment in speech and
communication OR serious impairment in several of the follo!ing"
occupational or school functioning, interpersonal relationships, %udgment,
thin&ing, or mood.
), - (- 4!esence of hallucinations o! "elusions /hich influence behaio!
OR serious impairment in ability to communicate !ith others OR serious
impairment in %udgment OR inability to function in almost all areas.
,, - )- here is some "ange! of ha!m to self o! othe!s OR occasional failure
to maintain personal hygiene OR the person is virtually unable to
communicate !ith others due to being incoherent or mute.
, - ,- 4e!sistent "ange! of ha!ming self o! othe!s OR persistent inability to
maintain personal hygiene OR person has made a serious attempt at
suicide.
GAF Scoring Vignettes
The following vignettes come from an e-mail thread on FORUM in November 1997. The vignettes were
resented b! "ohn #imson from the $roc%ton&'est Ro(b)r! *+M,. The e-mail has been edited to incl)de
onl! the vignettes and disc)ssion ertaining to the vignettes.
'n early October ())*, the 'P++ ,'ntensive Psychiatric +ommunity +are- team at the ./0+ in #roc&ton,
0assachusetts revie!ed all 12 patients in the program and as a team discussed and assigned G/3 scores to reflect
current functioning ,e.g., during the past month-. he follo!ing patients !ere then selected to illustrate specific G/3
ratings and to provide some guidance to program staff doing individual ratings in the future. he vignettes are
presented here in the hope they !ill be of interest and possible use to other ./ clinicians faced !ith periodically
assigning G/3 scores to chronic mentally ill outpatients.
he #roc&ton 'P++ team claims no special e4pertise !ith the G/3 5cale, although team members have been ma&ing
G/3 ratings for years as part of data collection underta&en by the Northeast Program 6valuation +enter ,N6P6+-.
Our e4perience has been that periodic team discussion helps substantially to reduce inter7rater variability and perhaps
helps control an apparent tendency to assign higher scores than are sometimes %ustified by a strict interpretation of
the G/3 scale. 8e !elcome any comments or questions concerning the follo!ing "anchors," and encourage other
programs to conduct similar e4ercises and ma&e the results available for discussion and mutual edification.
GAF 5 )-:
0r. / is a single veteran in his mid 92s !ho !as admitted to the 'P++ program about : years ago follo!ing lengthy
hospital stays and repeated failures to ad%ust to residential care placements. One residential care sponsor described
him as being very dependent and requiring constant supervision and attention. 0r. / !as rehospitali;ed in ()): !hen
he assaulted a residential care sponsor after she told him to ta&e a sho!er because he had been incontinent of feces.
<uring that admission he developed somatic delusions about having cancer, his /<=s continued to be very poor, and
he began to smear feces. 8ith 'P++ support, he !as discharged in Nov. ())> and placed in a rest home because he
required a high level of care and supervision of his /<=s. 0r. / attends activities at the community7based 'P++ day
program ? days a !ee&. @is speech is tangential and irrelevant at times, but he !ill usually cooperate if given e4plicit
directions. <espite the fact that 0r. / has been able to live outside the hospital for the past : years, he remains very
dependent on the rest home and 'P++ staff for all his needs, and smearing feces continues to be a problem.
+$RR6N G/3 R/NG6 ((7:2 ,"...O++/5'ON/==A 3/'=5 O 0/'N/'N 0'N'0/= P6R5ON/= @AG'6N6, 6.G.,
506/R5 36+65..."-
GAF 5 )):
0r. # is a veteran in his early B2s !ith a diagnosis of schi;oaffective disorder !ho has had multiple psychiatric
admissions, including (( in the past t!o years for severe delusions ,e.g., he believes he is a character from the =ittle
Rascals, that he has a girfriend !ho is a famous . actress, and that he o!ns seven businesses-. @e has e4tremely
poor money management s&ills, e.g., he is unable to purchase food and has been evicted for failure to pay his rent.
@e has a history of giving large sums of money a!ay ,i.e. C>227C(,222 at a time- to people ,often drug users- he %ust
met off the streets and considers his "friends" for religious reasons. @e refuses to participate in the community7based
'P++ day program and prefers to stay in bed much of the day. @e is noncompliant !ith ta&ing psychotropic
medications and attending outpatient appointments at the hospital. Recently, a conservator !as appointed to handle
his funds. +$RR6N G/3 R/NG6 :(7?2 ,"#6@/.'OR '5 +ON5'<6R/#=A 'N3=$6N+6< #A <6=$5'ON5" /N<
"56R'O$5 '0P/'R06N 'N ... D$<G606N" /N< "'N/#'='A O 3$N+'ON 'N /=0O5 /== /R6/5 ,6.G.,
5/A5 'N #6< /== </AE NO DO#...-."
GAF 5 )2:
0r. + is a single veteran in his late >2s !ho !as admitted to the 'P++ program on Duly (, ())9 after thirty years of
continuous hospitali;ation at the #./0+. @e no! lives in a residential care home and attends the 'P++ community7
based day program five days a !ee&. @e needs lots of prompting to attend to /<=s and uses an assisted
transportation system to attend the day program. @e hoards large amounts of money on his person and refuses to
open a ban& account, because he believes "the ban&s are controlled by the 0afia." @e continues to e4press bi;arre
delusions of a religious and grandiose nature, believing that he is the 5on of God and that he has the ability to
communicate !ith animals and e4traterrestrial beings. +$RR6N G/3 R/NG6 :(7?2 ,"#6@/.'OR '5
+ON5'<6R/#=A 'N3=$6N+6< #A <6=$5'ON5" /N< "56R'O$5 '0P/'R06N 'N ... D$<G606N"-
GAF 5 ).:
0r. < is a veteran in his mid B2s !ho !as discharged : years ago after (1 years of hospitali;ation. @e resides in a
residential care home and attends 'P++ community7based day programming > days/!&. @e is in a structured money
management program and receives concrete re!ards for completion of daily /<=s. @e is able to negotiate the city
transportation system and is very capable of accessing community resources. @e is e4tremely delusional, believing
that his body is made out of glass or !ood and believes that many people are his mother, including the queen mother
in 6ngland. @e is also very thought7disordered and tangentialE suspected brain damage contributes to speech
oddities. +$RR6N G/3 R/NG6 :(7?2 ,"#6@/.'OR '5 +ON5'<6R/#=A 'N3=$6N+6< #A <6=$5'ON5..."-
GAF 5 ():
0r. 6 is a single veteran in his mid >2s !ho has a long history of schi;oaffective illness characteri;ed by frequent
mood s!ings. 8hen in a manic phase, he e4ercises very poor %udgment regarding financial matters and his behavior
is very inappropriate. 8hen depressed he becomes sullen and !ithdra!n. @e also e4periences auditory hallucinations
at times. @e had numerous and lengthy hospitali;ations for his illness, although far fe!er and much shorter lengths of
stay since entry into the 'P++ program in ()1). @e has not been able to hold a %ob in many years. @is personal
hygiene is quite poor. @e resides in a boarding home !here he receives assistance !ith his medications. +$RR6N
G/3 R/NG6 ?(7B2 ,"...0/DOR '0P/'R06N 'N 56.6R/= /R6/5 5$+@ /5 8ORF OR 5+@OO=, 3/0'=A
R6=/'ON5@'P5, D$<G606N, @'NF'NG OR 0OO<"-
GAF 5 (2:
0r. 3 is a veteran in his early >2s !ho has had multiple admissions to the hospital. !o admissions during the past
year !ere for an increase in auditory hallucinations that !ere telling him to harm himself and others. @e continues to
hear voices but is able to separate out that they are not real and !ill not act on them. 'n some areas he functions
independently, for e4ample, he sho!ers and changes clothes daily, attends mass daily, and has a group of church
friends !ith !hom he has coffee. @e is compliant !ith appointments and medications ,even though he insists that
religion is better than the meds-, and gets along !ell !ith the other day program members and !ith the residents at
his residential care home. /t the community7based 'P++ day program, he follo!s through !ith his !or& assignment
and attends groups, !here he raises pertinent issues about community living and relates his personal e4periences.
@o!ever, he is very religiously preoccupied and has delusions about electricity, telephones and vehicles that are
impairing, e.g., because of his delusions he !ill not ride in cars. /s a result, he remains dependent on program staff
for some essential services. +$RR6N G/3 R/NG6 ?(7B2 ,"5O06 '0P/'R06N 'N R6/='A 65'NG" /N<
"0/DOR '0P/'R06N 'N 56.6R/= /R6/5, 5$+@ /5 8ORF OR 5+@OO=, 3/0'=A R6=/'ON5@'P5,
D$<G606N, @'NF'NG, OR 0OO<"-
GAF 5 32:
0r. G is a veteran in his early >2s !ho has had multiple hospitali;ations due to non7compliance !ith medications.
8hen he !as living in his o!n condo he !ould stop ta&ing meds and become very paranoid, !ith hallucinations. @e is
no! living in an apartment !ithin a residential care home, !here meals are provided and meds are supervised. @e
continues to e4perience some symptoms of paranoia and !ill have an occasional hallucination in !hich someone is
calling his name. @o!ever, he drives his o!n car and attends the 'P++ community7based day program, !here he is in
charge of collecting lunch monies and &eeping data for the programGs point7based re!ard system. @e usually &eeps to
his o!n at the day program and !hat conversations he has tend to be short, but he visits his family t!ice a month.
+$RR6N G/3 R/NG6 B(7>2 ,"56R'O$5 5A0PO05" /N< "56R'O$5 '0P/'R06N 'N 5O+'/=,
O++$P/'ON/= ... 3$N+'ON'NG"-
GAF 5 2):
0r. @ is a divorced in7country .ietnam .eteran in his late B2s !ith a dual diagnosis of schi;oaffective disorder and
alcoholism, although he has been abstinent from alcohol for several years and has not been overtly psychotic since
entry into the 'P++ program in ())2. @o!ever, he becomes very an4ious in social situations or !hen confronted !ith
a stressful situation. @e had not !or&ed for several years until t!o years ago !hen he obtained part7time employment
bagging groceries at a supermar&et. @e had some significant difficulties coping !ith the %ob and at one point became
depressed and required admission to inpatient psychiatry. @e currently is unemployed because he quit his part7time
%ob and attempted to !or& full time, but then quit !or&ing altogether !hen he felt unable to cope !ith the demands of
the ne! %ob. @e resides in a rooming home and manages his o!n medications and funds. +$RR6N G/3 R/NG6
>(792 ,"0O<6R/6 5A0PO05" /N< "0O<6R/6 <'33'+$=A 'N 5O+'/=, O++$P/'ON/=, OR 5+@OO=
3$N+'ON'NG"-
,omment&-)estion
he G/3 e4amples ,anchors- !ere very helpful. he need to be as accurate as possible !ith our G/3 scores has
ta&en on ne! importance !ith the mandate to provide these scores for all patients and their use in capitation formulas.
he information, e4amples, and opening of a dialogue provided by the #roc&ton 'P++ team is very valuable in
promoting this aim. 'n this regard, their illustrative "anchors" raised some questions for me ,perhaps because ' also
!or& !ith the severely mentally ill-"
(- o !hat degree must a patientGs behavior be influenced by their delusions or hallucinations to !arrant a G/3 belo!
?2H he e4amples of 0r. < I 3 raised this question. 0r. < has somatic delusions and delusions about others being
his mother ,plus disordered thin&ing-. 3rom !hat ' can tell from the information provided, ho!ever, they donGt seem to
effect his behavior "considerably." ' !ould be more inclined to give a G/3 of ?:7??.
he vignette about 0r. 3 raised the same question, but in the opposite direction. @e also has delusions, but they are
noted to be impairing. @is are about electricity, telephones and vehicles. On could conclude that if his life is
"considerably influenced," perhaps consistently significantly disrupted by these delusions that he might score more
closely to a :)7?2 on the G/3.
:- o !hat degree must a patientGs reality testing be intact to !arrant a G/3 above B2H his question !as raised by
the 0r. G vignette. 't notes that he has some symptoms of paranoia and an occasional /@ of someone calling his
name. Given the description, ' probably !ould not vie! him as having /@, but the "symptoms of paranoia" could be
vie!ed as impaired reality testing. his suggests the possibility of a lo!er G/3" ?)7B2.
?- o !hat degree must a patientGs general functioning improve ,moderate difficulty vs serious impairment- to !arrant
a G/3 above >2H he vignette about 0r. @ raised this question. 0r. @ tried to !or&, but ended up quitting because he
couldnGt cope !ith the demands of the %ob. o me this suggested serious occupational functioning, and ' !ould be
inclined to give him a G/3 score closer to B)7>2.
Resonse.
On behalf of the #roc&ton 'P++ team, !e appreciate the thoughtful comments concerning some of our G/3 ratings.
he points made are e4cellent and have prompted a good deal of discussion amongst the team ,hence the delay in
responding-.
/ general consideration is that our initial ratings !ere based on the teamGs clinical &no!ledge of the patients, and then
the vignettes !ere !ritten to try to summari;e the salient facts. 8e then 5@O$=< have rated the vignettes to ma&e
sure they !ere fully consistent !ith our ratings of the patients, but unfortunately !e did not. @ence, some of the
vignettes do not convey all the information used to ma&e the ratings. his probably accounts for some of the apparent
discrepancies, as discussed belo!.
/ second consideration is that !e attempted to apply the follo!ing guideline suggested by 0ichael 3irst, 0.<.
,"0astering <507'. /4is .." Drnl Prac. Psych. and #ehav. @lth., Nov. ())>, :>17:>)-" "treat the G/3 as if it !ere t!o
scales" one for symptom severity and another for level of functioning. JhenK ... ma&e one rating for severity and a
second for level of functioning. he !orst of the t!o can be used as the G/3." his is a useful approach in cases
!here there is some discrepancy bet!een the patientGs symptomatology and level of functioning, e.g., a patient !ith
psychotic symptoms !ho nevertheless functions fairly independently. his rating rule also helps counter7act an
apparent tendency to try to balance symptomatology and functioning or even to discount the !orse dimension and so
assign a patient a higher G/3 rating than is probably %ustified. $N3OR$N/6=A, !e no! reali;e that !e did not
al!ays follo! this rule strictly, and this probably accounts for some of the additional discrepancies that !ere noted.
' !ill no! address the specific questions in the order they !ere raised"
0r. < ,G/3 L :1-" @6 M$65'ON R/'56< '5 8@6@6R @6 <6=$5'ON5 NO6< 'N @6 .'GN66
/336+6< @'5 #6@/.'OR "+ON5'<6R/#=A" /5 R6M$'R6< 3OR / G/3 R/'NG 'N @6 :(7?2 R/NG6. his is
one of the cases !here !e rated the patient, but failed to rate the vignette and so did not reali;e that some essential
information !as missing from the vignette ,!hich by itself probably does not %ustify a G/3 belo! ?2-. he follo!ing
information about 0r. < is also relevant" his speech is almost unintelligible and his %udgment is very poor ,"56R'O$5
'0P/'R06N 'N +O00$N'+/'ON OR D$<G06N"-. 3or e4ample, he burned himself by someho! lighting his
poc&et on fire, but didnGt tell anyone and so the burns !ere only detected later by an 'P++ staff member !ho !as
assisting 0r. < in our supervised /<= program. 'n a separate instance, he !as bitten by a dog but again failed to tell
anyone, so medical assistance !as delayed. 8e believe these additional facts !ould support the assigned rating
,G/3 L :1-.
0r. 3 ,G/3 L ?>-" @6 M$65'ON 8/5 8@6@6R @6 <6=$5'ON5 NO6< "+ON5'<6R/#=A 'N3=$6N+6<"
@'5 ='36, 5$GG65'NG / G/3 5+OR6 'N @6 $PP6R 6N< O3 @6 :(7?2 R/NG6 8O$=< #6 0OR6
/++$R/6. his !as difficult to decide, but after much discussion the team agreed that 0r. 3 is influenced by his
delusions, but not "considerably." 3or e4ample, he manages to get around his delusion7imposed limitation of not riding
in cars by !al&ing or riding public transportation, and so generally functions adequately. his is obviously a %udgment
call, and on reconsideration !e !ould assign a lo!er score in the ?(7B2 range, namely G/3 L ?:.
0r. G ,G/3 L B>-" @6 M$65'ON '5 8@6@6R @6 5A0PO05 NO6< 'N @6 .'GN66 ,5O06 P/R/NO'/
/N< /N O++/5'ON/= /$<'ORA @/==$+'N/'ON- 'N<'+/6 "5O06 '0P/'R06N 'N R6/='A 65'NG"
/N< 5O 'N<'+/6 / G/3 R/'NG 'N @6 ?(7B2 R/NG6. $pon reconsideration, !e agree that 0r. GGs symptoms
meet the G/3 criterion of "some impairment in reality testing," and so the G/3 score should be revised do!n!ard,
e.g., to G/3 L ?1. JNote" this is a clear instance !here the team gave too much !eight to the patientGs relatively high
level of functioning 77 he drives his o!n car and successfully invests his o!n money 77 and not enough to his psychotic
symptoms. @o!ever, the rule of rating symptoms and functioning separately, and then pic&ing the lo!er rating, should
give the most !eight to the psychotic symptoms and thereby lead to the lo!ered G/3 score.K
0r. @ ,G/3 L >:-" @6 M$65'ON '5 8@6@6R 0R. @, 8@O 6N<6< $P M$''NG @'5 =/65 DO#, 0665
@6 G/3 +R'6R'ON O3 "/NA 56R'O$5 '0P/'R06N 'N ... O++$P/'ON/= 3$N+'ON'NG" 3OR / 5+OR6
'N @6 B(7>2 R/NG6. his is another instance !here the information provided in the vignette !as not adequate to
%ustify the rating assigned, but additional facts probably do %ustify the rating. 'n particular, 0r. @ !or&ed successfully
part7time for over t!o years, and then quit the part7time %ob in order to try full7time employment in a %ob !hich also
required a higher level of s&ill. @e couldnGt cope !ith this full7time position, so he quit that %ob and remains unemployed
because he did not go bac& to part7time !or&. @o!ever, his employment record suggests he is capable of holding
do!n a part7time %ob at an appropriate s&ill level, !hich !e !ould rate as moderate rather than severe difficulty in
occupational functioning. his is another difficult %udgment call, but !e prefer to maintain our rating of G/3 L >:.
'N +ON+=$5'ON" 8e greatly appreciate the above insightful comments, !hich have led us to revise our G/3 ratings
do!n!ard in t!o cases ,0r. 3 from ?> to ?:E and 0r. G from B> to ?1- and to provide additional information needed to
%ustify the G/3 ratings for 0essrs. < and @. 5ome of these issues are difficult to resolve, and disagreements !ill li&ely
persist. /s ' stated in my initial comments, !e claim no e4pertise in using the G/3, and are %ust trying to muddle
through li&e everyone else. 'n particular, !e have NO attempted to provide a sort of "gold standard" that other
respondents have mentioned. <espite these limitations, !e hope this discussion has been fruitful and !e loo& for!ard
to future e4changes of vie!s.
,omment
0any than&s to #roc&ton staff for initiating this discussion. ' note that the patient population at #roc&ton !as +0'
O$patients. 8e have rated a population of 'Npatients ? times this year, on a chronic !ard that has about B2N
"5/R '''" and 92N "5/R ''" patients. he first time !as on ?7?(7)*, and it came as a surprise to us...here !e !ere
doing the annual census in the middle of the yearO 8e &ept the scores, used them as a foundation for the ne4t rating
on 97?27)*. 8hen !e loo&ed at that distribution of ratings, !e &ne! some home!or& !as needed. 8e had rated each
patient independently of the others, and !e had used only scores divisible by >...nothing in bet!een. /nd !e had
clearly assigned higher scores than !ere !arranted ,the tendency noted above by #roc&ton staff-. 8e had not had
the benefit, ho!ever, of the sets of vignettes noted in this string.
5o !e got the original ()*9 paper on the G/5" 6ndicott, D., et al. he Global /ssessment 5cale. /rchives of General
Psychiatry, ()*9,??-, *997**(. 8e learned, "'n order to determine the scale point !ithin the ten7point interval, the
defining characteristics of the t!o ad%acent intervals are e4amined to determine !hether the sub%ect is closer to one or
the other." ,p. *99- 8e had found the "ladder" format of the <507'.Gs G/3, on p. ?:, rather difficult to use...it
scrambles together the symptom severity and level of functioning characteristics.
't boggled my brain to thin& of three intervals at any one time. 5o ' turned the scale from vertical to hori;ontal, in order
to have the perceptual/conceptual benefits of a =i&ert7type scale, and this helped us a lot. Only the !ords of the <50
itself !ere used, but no! displayed in a !ay that loo&s more li&e a continuum"
6o!i7ontal GAF 8ating Scale
On the page, the top ro! therefore has > cells !ith information, the ne4t ro! has : cells ,personal hygiene-, the ne4t
ro! has ? cells ,the ma%or theme being communication-, and the bottom ro! has ? cells ,level of psychosocial
functioning-. 8e then used this form on the third rating occasion, the end of year census, in a treatment team meeting.
6ach patient !as rated individually, using the G/3 characteristics, then !e compared patients !ho seemed to have
similar scores. 8e thin& our rating this time !as more valid and more reliable, but !e &no! !e still have much to
learn.
,omment
he ne! <irective )*72>) entitled, 'nstituting Global /ssessment of 3unction ,G/3- 5cores in /4is . for 0ental
@ealth Patients, !as signed off by <r. Fi;er, dated November :>, ())*.