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News Gram™ May 2006

May 2006 ~ Volume 12, No. 10

By now, we all know the altered landscape of Workers’ Compensation in California. What is not so clear, though, are the myriad details surrounding medical evaluations. It turns out that psychiatric claims (stress claims) may now be among the most expensive within the entire spectrum of conditions encountered in the system. It’s more important than ever to understand the way psychiatrists diagnose their patients and, in particular, how they understand something called the Global Assessment of Functioning – the GAF.

The Diagnostic and Statistical Manual of Mental Disorders (4th Edition) of the American Psychiatric Association (DSM-IV), the “bible” of psychiatric practice in the United States, is based on a multi-axial system of diagnosis. Axis I includes all the diagnoses in the full classification with the exception of personality disorders and mental retardation. Major Depression, Bipolar Disorder, Schizophrenia and Anxiety Disorder are but a few examples of the Axis I diagnoses listed in the DSM-IV. Axis II consists of Personality Disorders and Mental Retardation. These are enduring states of the person that are treated separately as a result. Axis III is reserved for General Medical Conditions that may be relevant to understanding and treating the individual’s psychiatric difficulty. Axis IV includes Psychosocial and Environmental Problems. These include problems with the primary support group, economic problems and housing problems, among others. Axis V is the GAF.

Assigning a numerical value to “how a person is doing” is not an easy task. The reason is that the psychiatrist is charged with evaluating the individual in a number of different spheres, after which he or she must combine these findings into a single quantitative result. The scale runs from 0 (Inadequate information) to 100 (Superior functioning). When the number is, say, 67, the reason must be a psychiatric factor that is impairing the full functioning of the person. The spectrum of functioning is as follows:

The judgment of the psychiatrist is critical when it comes to the determination of the GAF. There are no simple forms to fill out or computer programs that address the whole person. A careful assessment of the person in such spheres as cognitive functioning, linguistic ability, reality testing, appreciation of social norms and cues, awareness of oneself and ability to regulate affect, as well as various other areas of personal life require not just a mechanical approach to a patient evaluation but an understanding of other people that ultimately transcends the narrow confines of psychiatric diagnosis. There has been considerable research done on the GAF and rater reliability but we can regard this part of the DSM-IV as an ongoing project.

Additionally, in a society as diverse as that of the United States, various symptoms will be regarded differently depending on one’s cultural, esthetic and moral values. Those from a tribal background or any group influenced by shamanistic practices may regard hallucinations as divine messages to privileged members of their group. Many immigrant groups disregard what Americans refer to as psychiatric disorders or conditions, preferring to think in moral terms. Gang members may not regard shoplifting – persistent or otherwise – as abnormal behavior. Presumably, the psychiatric criteria that help explain various behaviors are free of social or political values, but that is not true by a longshot. In the end, the patient must rely on the psychiatrist to appreciate the cultural differences that separate the patient (and his family) from the assessing and treating physician. If the psychiatrist is to be effective in his evaluative and therapeutic role, then he or she must understand the differences in the way different groups of individuals see the world.

For all its weaknesses, the GAF is a worthwhile attempt to grasp the overall way in which people adjust to their environment. The use of the GAF in the Workers’ Compensation system will be interesting to track. While it may constitute a substantial improvement over the now obsolete Work Function Impairment Form, it can be abused in ways that do not advance the best interests of the patient. In the case of the GAF, it is best to know the psychiatrist who is evaluating the claimant.

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