GAF Score

[sethco]

Was wondering whether or not the Global Assessment of Functioning (GAF) is a composite score and if so what are the individual components and how are they scored?

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[wolfvgang22]

Was wondering whether or not the Global Assessment of Functioning (GAF) is a composite score and if so what are the individual components and how are they scored?

You could google this you know. http://en.wikipedia.org/wiki/Global_Assessment_of_Functioning

 

[Hurricane]

I find the GAF to be totally useless.

 

[billypilgrim37]

I find the GAF to be totally useless.

But how else can you signal to an MBA how sick you think somebody is?

 

[sethco]

I know it is completely useless, but I was just wondering is this a score by itself or are there multiple categories that add up to the composite score

 

[OldPsychDoc]

I know it is completely useless, but I was just wondering is this a score by itself or are there multiple categories that add up to the composite score

It's a score by itself--a "global" assessment.

(And it's still useless! )

 

[marie337]

I must admit, I'm not totally comfortable with assigning a GAF score. It just seems unscientific to me and very operator dependent whether to choose 30-35 or 35-40 for instance. What rules do you go by when applying a score?

 

[erg923]

You are suppose find the range that has the appropriate symptomatology OR level of functional impairment, which ever is worse. In other words, both the symptoms AND the impairment should be worse on the ten point range below the one you picked. Once you find your appropriate ten point range, you will settle on the upper half or lower half depending on whether the client has a minimal amount of symptomatology or functional impairment specified by that range (in which you would chose closer to 31) or a relative predominance of the symptoms or impairment (in which case you would be up closer to 40). Instructions for all this are specified in the DSM. I agree, it is such a gross and crude measure, it is pretty much useless. Not much attention is paid to it clinically in my experience, but I do alot of SCIDs in a research setting, so its part of my duties there.

The SCID is a whole other discussion. I think Nancy Andreasen said it best when she said the DSM has given us reliability, but sacrificed true validity, by squelching the time honored tradition of researching phenomenology and taxons. DSM diagnoses have given researchers a
common nomenclature—but probably the wrong one.

 

[Hurricane]

I must admit, I'm not totally comfortable with assigning a GAF score. It just seems unscientific to me and very operator dependent whether to choose 30-35 or 35-40 for instance. What rules do you go by when applying a score?

In theory, what erg924 said. In reality, if they need to be hospitalized, they get a 20. When they are ready for discharge, 50. Insurance has kinda forced people into this backwards way of assigning the GAF, which totally defeats the purpose for which it was intended.

 

[sethco]

Thanks all for responses. I always see this number on my patient's Life Skills notes and I always wondered how they came to this score

 

[beezley]

I guess I don't find it too useful other than you want the score to be higher upon D/C from the psych ward than it is upon admission.. I was just joking about it with one of my attendings, likening scoring above 90 to being 'self-actualized' i.e. no one ever gets there except people like Jesus, Buddha or in current times the Dalai Lama or Mother Teresa. Kind of strange to think about your own GAF when as medical students/residents/physicians we are used to scoring very high on everything.

I love how pregnancy makes it possible for me to be up blogging about such things at 3am, that probably lowers my GAF score.

 

[billypilgrim37]

...likening scoring above 90 to being 'self-actualized' i.e. no one ever gets there except people like Jesus...

that made me spit Mountain Dew all over myself

fortunately I can just blame it on the old guys upstairs who keep falling because they like to watch me do paperwork!

i'm not paranoid, i swear

 

[marie337]

i.e. no one ever gets there except people like Jesus, Buddha or in current times the Dalai Lama or Mother Teresa.

Not to start a religious debate, but some people might argue that Jesus was delusional ! The Dalai Lama and Mother Teresa I don't think any one could argue with though.

 

[strangeglove]

Not to start a religious debate, but some people might argue that Jesus was delusional ! The Dalai Lama and Mother Teresa I don't think any one could argue with though.

Yes, this could be true, but you can't deny that he was pretty high-functioning; functioning is part of the GAF, not just sx.

 

[erg923]

...yes, but remember, you go with whichever is worse: symptoms OR functioning. If you are grossly delusional, your GAF can not be higher than 40, no matter how high functioning you are. This is why the name is total misnomer, its not always representative of actual functioning.

 

[rhiannon777]

Reviving this old thread....

Is it true that insurance companies won't pay for the patient's hospitalization if he or she is above a certain GAF? It seems so subjective and kind of useless -- I feel like I could easily give the same patient a 25 or 50. Is there any better strategy or algorithm for assigning these scores?

 

[Sarah Bellum]

Reviving this old thread....

Is it true that insurance companies won't pay for the patient's hospitalization if he or she is above a certain GAF? It seems so subjective and kind of useless -- I feel like I could easily give the same patient a 25 or 50. Is there any better strategy or algorithm for assigning these scores?

I got a GAF of 55. At the time I was taking physics, biology, chemistry, and a graduate-level course (all A's), working 40 hours/week, and taking care of my two children. I had minor depression and some anxiety after I almost lost my baby and my life during pregnancy. It wasn't bad enough to affect my functioning, but I still got a fairly low score. A little bit lower, and I could have qualified for disability!

Some insurance companies do ask for GAF scores when the utilization nurse gives them updates. A GAF score is taken into consideration with other things concerning the severity of the illness and the intensity of service provided.

 

[wolfvgang22]

Generally a GAF of 35 or less is what utilization review nurses or the sith spawn physician working for the insurance company will accept to justify inpatient hospitalization. As far as I know its an arbitrary number. I dont think a patient is magically less DTO/DTS at a GAF of 40. In fact, a patient suffering depression may be more likely to harm self with a slightly higher GAF as they are less neurovegetative and able to carry out a suicide plan. In most inpatient facilities you see a patient admitted with a GAF of 20, and then magically improve to around 50 the morning of discharge a week later, in order to appease the payor who would otherwise deny coverage.

 

[wolfvgang22]

Reviving this old thread....

Is it true that insurance companies won't pay for the patient's hospitalization if he or she is above a certain GAF? It seems so subjective and kind of useless -- I feel like I could easily give the same patient a 25 or 50. Is there any better strategy or algorithm for assigning these scores?

I like the GAF. As you imply, It's not meant to be super precise or used to deny coverage. It's a birds eye view of how a person is doing overall from a subjective, human standpoint. Its an acknowledgement that human biopsychosocial interactions are complex and not necessarily reducible to a simple algorhythm which could be run on a computer in lieu of careful diagnosis of maladaptive cognitions and behaviors by an experienced clinician over time. The practice of psychiatry might be easier if this were not true. Despite all the various rating scales and treatment protocols, which have their important uses, psychiatry remains as much a human art as a science. Clinicians vary in their ability to accept this.
In short: no, there isn't a much better way. Maybe an opportunity for you to develop something?

 

[whopper]

I can tell you that in malpractice cases, where the plaintiff wants to make the doctor look like an incompetent practitioner, things like GAF do matter.

"Dr, you diagnosed the patient with a GAF of 45. Can you state the exact criteria for a GAF of 45?"

"Doctor why not give a GAF of 65, or 35?"

So when a doctor gives a GAF, and can't state an exact reason why they did what they did, they look like an idiot on the stand, and lots of doctors give a GAF as if they're critiquing abstract art.

If all doctors did the GAF as accurately as possible then it would matter. During residency, no doctor I knew took it seriously other than to put a number down that would back up what billing companies were looking for, and that appears to be the current norm.

But when I hit fellowship, my PD mentally slapped me silly (in a good way) to make me take those numbers seriously. In hindsight, I thought about it, and remembered that no one, literally no one made me do the DSM GAF the exact way it was supposed to be done until fellowship. Yes there is an exact procedure on how to do it. Don't believe me, read it in the DSM. I never read the DSM in a manner where I read it page after page, starting from beginning to end until fellowship. I just used it for reference. While I did read the DSM scale, I never actually did it procedurally the way the DSM tells you how to do it because no one in residency told me to, and I noticed I was actually putting more effort to be accurate with my GAF number than my attendings.

If everyone did it the way the DSM tells you how to do it, the number would matter, but hardly anyone does.

I've given a GAF of zero much more after fellowship because my PD got me "straightened out" so to speak. Zero is not worse than a GAF of one. Zero means you don't have enough information. I've had several people in medical records call me up and explain to me there is no zero score. I tell them to double check the DSM, and then usually about 15 minutes later they call up and apologize.

I agree with the above, however, that there can't be 100% accuracy and reliability between psychiatrists when doing a GAF< but if psychiatrists did it the right way, it shouldn't deviate by more than 10 points, because the criteria in the scale ask for things that psychiatrists are supposed look for such as the severity of the symptoms or the person's ability to function in society.

 

[erg923]

Finding the appropriate 10 point range should really not be all that subjective. Your judgment on whether they are at the top, middle or bottom of that range is usually tricky though.

 

[nitemagi]

The GAF was based on the GAS, which I liked reading as it gave a few more hints for ratings --
http://www.ncbi.nlm.nih.gov/pubmed/938196

I put together my own algorithm to try and narrow down ratings. There should overall be pretty good interrater reliability within 10 points. Like any other psychometric, poor interrater reliability may indicate poor training, or as hinted at by many, a poor measure itself. I agree with those above that one should focus on the most impairing symptom or area of impairment.