Do we have to use the GAF?

During my short time as a psychiatry resident, I have found the DSM-IV (TR) lacking in many regards. On this I know I am not alone, and I appreciate the many reasons for its limitations. I have always questioned the usefulness of the Global Assessment of Functioning. I personally find it utterly useless. When I read a colleague's assessment of a patient my eyes aren't immediately drawn to Axis V to see the GAF. In fact, I rarely ever look at it. What can it really ever tell you? This is someone's subjective, overall measurement of...well...that's the problem. Per DSM's guidance, we are supposed to base the GAF on whichever is worse, severity of symptoms or impairment in functioning. That simple distinction, severity versus functioning, isn't' even mentioned after the number. Furthermore, even if severity or functioning was parenthesized after the number (i.e. GAF = 40 (functioning), questions abound: Functioning impaired how? Which symptom's severity warrants a GAF of 40?

Personally, I think the GAF promotes academic laziness, in as much as it requires very little (if any) thought. I am as guilty as the next person. I occasionally look at the GAF scale in the DSM to find the most appropriate number, but often it's just some number off the top of my head. Doing well?  70.  Not so great?  50?  Admitting?  20.  Again, I'm as guilty as the next person. 

Per DSM-IV (TR):

Axis V is for reporting the clinician's judgment of the individual's overall level of functioning. This information is useful in planning treatment and measuring its impact, and in predicting outcome. The reporting of overall functioning on Axis V can be done using the Global Assessment of Functioning (GAF) Scale.

In some settings, it may be useful to assess social and occupational disability and to track progress in rehabilitation independent of the severity of the psychological symptoms...Two additional proposed scales that may be useful in some settings -- the Global Assessment of Relational Functioning (GARF) Scale and the Defensive Functioning Scale.

I propose that the Defensive Functioning Scale would be immensely more useful than the number "42," and that whoever reads our notes later down the road will appreciate having a more descriptive Axis V. With that said...documentation already takes too long, so you can expect to see more "42"s on my Axis V!

Defensive Functioning Scale

Defense mechanisms (or coping styles) are automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. Individuals are often unaware of these processes as they operate. Defense mechanisms mediate the individual's reaction to emotional conflicts and to internal and external stressors. The individual defense mechanisms are divided conceptually and empirically into related groups that are referred to as Defense Levels. To use the Defensive Functioning Scale, the clinician should list up to seven of the specific defenses or coping styles (starting with the most prominent) and then indicate the predominant defense level exhibited by the individual. These should reflect the defenses or coping styles employed at the time of evaluation, supplemented by whatever information is available about the individual's defenses or coping patterns during the recent time period that preceded the evaluation. The specific defense mechanisms listed may be drawn from the different Defense Levels. The Defensive Functioning Axis is presented first, followed by a recording form. The rest of the section consists of a list of definitions for the specific defense mechanisms and coping styles.

Defense Levels and Individual Defense Mechanisms

High adaptive level. This level of defensive functioning results in optimal adaptation in the handling of stressors. These defenses usually maximize gratification and allow the conscious awareness of feelings, ideas, and their consequences. They also promote an optimum balance among conflicting motives. Examples of defenses at this level are

Mental inhibitions (compromise formation) level. Defensive functioning at this level keeps potentially threatening ideas, feelings, memories, wishes, or fears out of awareness. Examples are

Minor image-distorting level. This level is characterized by distortions in the image of the self, body, or others that may be employed to regulate self-esteem. Examples are

Disavowal level. This level is characterized by keeping unpleasant or unacceptable stressors, impulses, ideas, affects, or responsibility out of awareness with or without a misattribution of these to external causes. Examples are

Major image-distorting level. This level is characterized by gross distortion or misattribution of the image of self or others. Examples are

Action level. This level is characterized by defensive functioning that deals with internal or external stressors by action or withdrawal. Examples are

Level of defensive dysregulation. This level is characterized by failure of defensive regulation to contain the individual's reaction to stressors, leading to a pronounced break with objective reality. Examples are

Recording Form: Defensive Functioning Scale

A. Current Defenses or Coping Styles: List in order, beginning with most prominent defenses or coping styles.

1. __________________________________________
2. __________________________________________
3. __________________________________________
4. __________________________________________
5. __________________________________________
6. __________________________________________
7. __________________________________________

B. Predominant Current Defense Level: _____________________________

A. Current Defenses or Coping Styles:

  1. splitting
  2. projection identification
  3. acting out
  4. devaluation
  5. omnipotence
    6. denial
  6. projection

B. Predominant Current Defense Level: major image-distorting level

Glossary of Specific Defense Mechanisms and Coping Styles

acting out

The individual deals with emotional conflict or internal or external stressors by actions rather than reflections or feelings. This definition is broader than the original concept of the acting out of transference feelings or wishes during psychotherapy and is intended to include behavior arising both within and outside the transference relationship. Defensive acting out is not synonymous with "bad behavior" because it requires evidence that the behavior is related to emotional conflicts.

affiliation

The individual deals with emotional conflict or internal or external stressors by turning to others for help or support. This involves sharing problems with others but does not imply trying to make someone else responsible for them.

altruism

The individual deals with emotional conflict or internal or external stressors by dedication to meeting the needs of others. Unlike the self-sacrifice sometimes characteristic of reaction formation, the individual receives gratification either vicariously or from the response of others.

anticipation

The individual deals with emotional conflict or internal or external stressors by experiencing emotional reactions in advance of, or anticipating consequences of, possible future events and considering realistic, alternative responses or solutions.

autistic fantasy

The individual deals with emotional conflict or internal or external stressors by excessive daydreaming as a substitute for human relationships, more effective action, or problem solving.

denial

The individual deals with emotional conflict or internal or external stressors by refusing to acknowledge some painful aspect of external reality or subjective experience that would be apparent to others. The term psychotic denial is used when there is gross impairment in reality testing.

devaluation

The individual deals with emotional conflict or internal or external stressors by attributing exaggerated negative qualities to self or others.

displacement

The individual deals with emotional conflict or internal or external stressors by transferring a feeling about, or a response to, one object onto another (usually less threatening) substitute object.

dissociation

The individual deals with emotional conflict or internal or external stressors with a breakdown in the usually integrated functions of consciousness, memory, perception of self or the environment, or sensory/motor behavior.

help-rejecting complaining

The individual deals with emotional conflict or internal or external stressors by complaining or making repetitious requests for help that disguise covert feelings of hostility or reproach toward others, which are then expressed by rejecting the suggestions, advice, or help that others offer. The complaints or requests may involve physical or psychological symptoms or life problems.

humor

The individual deals with emotional conflict or external stressors by emphasizing the amusing or ironic aspects of the conflict or stressor.

idealization

The individual deals with emotional conflict or internal or external stressors by attributing exaggerated positive qualities to others.

intellectualization

The individual deals with emotional conflict or internal or external stressors by the excessive use of abstract thinking or the making of generalizations to control or minimize disturbing feelings.

isolation of affect

The individual deals with emotional conflict or internal or external stressors by the separation of ideas from the feelings originally associated with them. The individual loses touch with the feelings associated with a given idea (e.g., a traumatic event) while remaining aware of the cognitive elements of it (e.g., descriptive details).

omnipotence

The individual deals with emotional conflict or internal or external stressors by feeling or acting as if he or she possesses special powers or abilities and is superior to others.

passive aggression

The individual deals with emotional conflict or internal or external stressors by indirectly and unassertively expressing aggression toward others. There is a facade of overt compliance masking covert resistance, resentment, or hostility. Passive aggression often occurs in response to demands for independent action or performance or the lack of gratification of dependent wishes but may be adaptive for individuals in subordinate positions who have no other way to express assertiveness more overtly.

projection

The individual deals with emotional conflict or internal or external stressors by falsely attributing to another his or her own unacceptable feelings, impulses, or thoughts.

projective identification

As in projection, the individual deals with emotional conflict or internal or external stressors by falsely attributing to another his or her own unacceptable feelings, impulses, or thoughts. Unlike simple projection, the individual does not fully disavow what is projected. Instead, the individual remains aware of his or her own affects or impulses but misattributes them as justifiable reactions to the other person. Not infrequently, the individual induces the very feelings in others that were first mistakenly believed to be there, making it difficult to clarify who did what to whom first.

rationalization

The individual deals with emotional conflict or internal or external stressors by concealing the true motivations for his or her own thoughts, actions, or feelings through the elaboration of reassuring or self-serving but incorrect explanations.

reaction formation

The individual deals with emotional conflict or internal or external stressors by substituting behavior, thoughts, or feelings that are diametrically opposed to his or her own unacceptable thoughts or feelings (this usually occurs in conjunction with their repression).

repression

The individual deals with emotional conflict or internal or external stressors by expelling disturbing wishes, thoughts, or experiences from conscious awareness. The feeling component may remain conscious, detached from its associated ideas.

self-assertion

The individual deals with emotional conflict or stressors by expressing his or her feelings and thoughts directly in a way that is not coercive or manipulative.

self-observation

The individual deals with emotional conflict or stressors by reflecting on his or her own thoughts, feelings, motivation, and behavior, and responding appropriately.

splitting

The individual deals with emotional conflict or internal or external stressors by compartmentalizing opposite affect states and failing to integrate the positive and negative qualities of the self or others into cohesive images. Because ambivalent affects cannot be experienced simultaneously, more balanced views and expectations of self or others are excluded from emotional awareness. Self and object images tend to alternate between polar opposites: exclusively loving, powerful, worthy, nurturant, and kind¾or exclusively bad, hateful, angry, destructive, rejecting, or worthless.

sublimation

The individual deals with emotional conflict or internal or external stressors by channeling potentially maladaptive feelings or impulses into socially acceptable behavior (e.g., contact sports to channel angry impulses).

suppression

The individual deals with emotional conflict or internal or external stressors by intentionally avoiding thinking about disturbing problems, wishes, feelings, or experiences.

undoing

The individual deals with emotional conflict or internal or external stressors by words or behavior designed to negate or to make amends symbolically for unacceptable thoughts, feelings, or actions.

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