LITIGATION PROBLEMS WIH THE GAF
Statements about an applicant’s level of permanent psychiatric disability rest upon the doctor’s conclusions about their Global Assessment of Functioning (GAF). According to the Schedule for Rating Permanent Disabilities each GAF score bears a corresponding Whole Person Impairment (WPI) score.
GAF scores of 70 or above have a WPI score of 0. GAF scores of 40 or less have WPI scores greater than 50. GAF scores that are above 70 or below 40 are not typically problematic in workers’ compensation cases unless the doctor has made a gross error. The GAF scale is defined on page 34 of the DSM-IV-TR. Here are the DSM-IV-TR definitions for the most relevant scores for worker’s compensation purposes.
70 — “Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.”
60 — “Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., no friends, unable to keep a job).”
50 — “Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupation, or school functioning (e.g., no friends, unable to keep a job).”
40 — “Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).”
The DSM-IV-TR and the Schedule for Rating Permanent Disabilities are both very clear in stating that intermediate numbers such as 45, 58 and 64 are to be used when judged appropriate.
The assignment of numbers to an applicant’s functioning would seem to suggest that there is some objectivity to the GAF method. However, on closer look there often is a great deal of subjectivity that is completely dependent on the doctor’s opinion and their ability to support that opinion with data obtained during the clinical examination.
The biggest problem with subjectivity in the GAF scale revolves around the word “OR” that the DSM-IV-TR very carefully puts in capital letters and boldface, as if it would otherwise be missed. All the criteria that are presented before the word “OR” are easily understood and clearly observable, one way or another, during the doctor’s examination. Specifically, there is little room for an interpretation of “depressed mood;” “circumstantial speech;” “occasional panic attacks;” and illogical, obscure or irrelevant speech. All of these phenomena are easily observed either directly during the face-to face clinical interview or in the taking of the history from a credible patient.
However, major problems arise for any evaluating physician when they base their opinions on the criteria that come after the word “OR.” Specifically, just what is the nature of “some difficulty,” “moderate difficulty,” “serious impairment,” and “major impairment?” Nowhere in the DSM-IV-TR are these terms defined and there are no generally accepted definitions. While it is clear that as you move further down the list there is more impairment, just where you stop for any given case is a matter of clinical judgment.
The bottom line here is that the doctor needs to be fully prepared to defend their conclusions that there is “some difficulty,” “moderate difficulty,” “serious impairment” and “major impairment” with objective data from the examination that supports a believable conclusion. In this regard, the DSM IVTR is not helpful in providing any such guidance beyond what is given above.
Overall, it would be a wise physician indeed who constructed their own definitions of the terms such as “moderate difficulty” and “serious impairment” that appear on this GAF scale prior to assigning any values to a given applicant. Similarly, it would also be a wise attorney who, when not satisfied with a doctor’s summarily stated conclusions, would prepare to ask tough questions in the deposition about the definitions the doctor has used and their supporting data.
Perhaps it would be helpful to know that in my practice I have found the following definitions to be clear and defensible:
“some difficulty” — evidence that the individual can work but will have behavioral lapses that will affect their performance in a negative manner
“moderate difficulty” — evidence that the individual can work but will have some shortcomings and lapses in behavior and is susceptible to losing their job as a result of those deficit
“serious impairment” — evidence that the individual has a very limited capacity for working and can only do so for a relatively short period of time, presenting a barrier for maintaining their job
“major impairment” — evidence that the individual is not capable of performing their job as a result of behavioral deficits