My understanding is that the GAF had limited validity and utility. The decision of DSM-5 to remove it reflects the lack of acceptance and use it generally had within the therapeutic community. The DSM itself questioned its validity due to the conflating of disability/suicidality and symptom severity. A limited search also suggests that its reliability varied, although there is suggestion that with training this can improve (i.e., reliability is better in research vs. clinical settings) - e.g., http://www.ncbi.nlm.nih.gov/pubmed/21223457; http://ps.psychiatryonline.org/article.aspx?articleid=89892; http://www.ncbi.nlm.nih.gov/pubmed/17355524. One of these articles also notes that the measurement error may make the scale poor for detecting change within an individual.

Given that the DSM itself has disposed of the GAF it may be better to focus on other assessment scales, for example, the DSM-5's suggested alternative of the WHODAS http://www.who.int/classifications/icf/whodasii/en/

To quote the DSM - "DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, representing the clinician's judgment of the individual’s overall level of “functioning on a hypothetical continuum of mental health–illness.” It was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In order to provide a global measure of disability, the WHO Disability Assessment Schedule (WHODAS) is included, for further study, in Section III of DSM-5 (see the chapter “Assessment Measures”). The WHODAS is based on the International Classification of Functioning, Disability and Health (ICF) for use across all of medicine and health care. The WHODAS (version 2.0), and a modification developed for children/adolescents and their parents by the Impairment and Disability Study Group were included in the DSM-5 field trial."

Dear Richard,

Thank you for your contributions. I share your Position. But in addition to that I am interested what clinicans are thinking about the reliability using the GAF for routine diagnostics.

Dear Sean

I am not sure that the GAF will reach 100% reliability. Different researches demonstrates us a interrater reliability calculated at .74 (Hilsenroth et al., 2000).

Hilsenroth, M. J., Ackerman, S. J., Blagys, M. D., Baumann, B. D., Baity, M. R., Smith, S. R., et al. (2000) Reliability and validity of DSM-IV axis V. American Journal of Psychiatry, 157(11), 1858-1863.

Greetings

Egon

Hi Egon, can you clarify what you wish to use the GAF for? Richard.

Dear Richard,

We are using it as a screening-instrument to detect patients with egostructrural deficits (personality disorders). This depending on empirically demonstrated high correlation between Axis II and Axis V DSM IV: (Hilsenroth et al. 2000).

best regards

Egon

Hi Egon, I would second what David has noted, the GAF may point to more severe disability that could indicate a personality disorder, but wouldn't be specific to that. For example, someone with a low GAF score could have a personality disorder, but equally could have psychosis, dementia,"just" a severe (DSM-IV) Axis I problem, etc. etc., while someone with a personality disorder may not necessarily come off as poorly functioning by the GAF (e.g., OCPD/anankastic may function quite well in some circumstances, similarly avoidant, etc.) It may also be influenced though by the setting you're in - e.g., if you're in an outpatient clinic that tends to see depression/anxiety then it may be somewhat more indicative there (i.e., if you don't get patients with psychosis, etc.) but still not that specific. However, I think the idea of routinely quantifying functioning and quality of life (whatever the method) is a good one anyway! Richard

This is also the basic assumption of Hilsenroth et al. (2000). The GAF is not specific for PD (Axis II) but highly correlated. The GAF indicates the severity of problems and interpersonal functioning over the last 2 years; I think it indicates a high correlation with OPD Axis IV (operationalized psychodynamic diagnostics OPD 2006) or LPFS (Level of Personality Functioning scale, DSM V). I think GAF, OPD, LPFS have a wide range of commonalities, but also differences reflecting diferent backgrounds. They are not congruent, but all three approaches (psychiatric and psychodynmic) for dimensional diagnosis relate to interpersonal problems of patients; tey are central for PD.

thanks

Egon

The DSM is not much use for anything according to according to the current and former directors of the National Institute for Mental Health. According to Dr Thomas Insel, current director. The DSM is...

“at best, [the DSM is] a dictionary, creating a set of labels and defining each. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

Dr Steven Hyman, a neuroscientist and former director acknowledged...

That there is no real theoretical basis for current drug treatments for mental illness. He noted that existing treatments have not changed since the 1950s, and don’t work to improve the lives of people who suffer from real mental illnesses:

“many patients with mental disorders remain symptomatic and often disabled despite existing treatments. For some significantly disabling conditions, such as the core social deficits of autism and the cognitive impairments of schizophrenia, there simply are no effective treatments.”

“The molecular actions of all widely used antidepressants, antianxiety drugs, and antipsychotic drugs are relatively unchanged from their 1950s prototypes. Current antidepressants alter levels of the neurotransmitters serotonin or norepinephrine in synaptic connections between certain nerve cells in the brain. This is the same basic action of the first modern antidepressant imipramine, discovered in 1957. Antipsychotic drugs act on several different neurotransmitter receptors in the brain, but the critical shared mechanism of all current antipsychotic drugs is blockade dopamine D2 receptors, the same mechanism of the prototype antipsychotic drug chlorpromazine, discovered in 1950.”

GAF gives you a better picture of the intensity/impact of Axis I and Axis IV, particularly if you look at current and 1 year ago. Although it is removed, it was replaced with a Severity Index (Mild, Moderate, Severe) that roughly translates to:

Mild 61-70

Moderate: 31-60

Severe: 0-30

Although this is meant to improve inter-rater reliability, it leaves too wide a gap (opinion) in the Moderate range.

In terms of Axis II, I think you would need to look at the spectrum of ego syntonic vs ego dystonic. Would someone with Narcissistic Personality Disorder agree with your GAF score rating of their life? How about someone who has Antisocial Personality Disorder? The only one you could count onto agree with you would be your person with Dependent Personality Disorder.

In short, no, I dont think you have a strong link between Axis V and Axis II, despite Axis II likely being the characterological source of the events that influence the rating on Axis V

I feel that a conceptual problem with the GAF is that it intermixes symptom severity with functional impairment. Most of the text descriptions in the scale provide examples of each. Any such attempt to model two completely distinct constructs on a single scale is likely to run into difficulty.

The acquisition of interpersonal problems (GAF) is just one part of the GAF. Nevertheless, there are moderate correlations to axis II. DSM 5 will actually bring improvements in this area (level of personality functioning) . The two dimensions of "Self" and "Interpersonal" will be more specific for personality disorders than the two dimensions of the GAF symptomatic stress and interpersonal problems. For example they are more congruent to OPD-2 Axis IV "Self-perception" and "communication and attachment".

Thanks

Egon

dear Armin

Thank you very much for your contribution

Egon