Changing How the VA Rates Mental Conditions: GAF vs. WHODAS 2.0
There are a number of mental health disorders that the VA recognizes and can grant service connection for. Some examples of the most common ratings we see are post-traumatic stress disorder (PTSD), major depressive disorder (MDD), general anxiety disorder, and bi-polar. Each of these mental health disorders are described by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, more commonly referred to as the DSM-V.
Prior to the DSM-V, the VA used the DSM-IV-TR for rating mental disorders which was published in 2000. The DSM-IV employed what is referred to as a global assessment of functioning (or GAF) score to rate the severity of a mental disability that a veteran suffers. GAF scores are assigned to assess the impact of a veteran’s disability on his social, occupational, and psychological functioning. GAF scores range from 0 – 100. A score of 0 represents total impairment, and a score of 100 would represent normal functioning. It is generally accepted that a GAF score below 50 represents serious to severe social impairment. The VA has used GAF scores in their determination of the impact that mental illness has on the affected individual.
GAF scores have been criticized for being too subjective to be reliable in reporting the actual impairment caused by a mental disorder. Generally, a rater’s training and performance are essential to a GAF score’s reliability. GAF scores often correlate more with the severity of the symptoms that an individual is experiencing rather than the functional impact those symptoms have on an individual in day to day situations. These are just some of the reasons that the DSM-V has decided to exclude GAF scores as less than adequate in rating mental disorders. In the place of GAF, the DSM-V uses the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0).
The writers of the DSM-V recommend WHODAS 2.0 is the best current assessment of disability for clinical uses. The first difference between GAF and WHODAS is how it rates mental disorders and the resulting disability. Rather than assigning a single numerical score, WHODAS separates the medical and psychiatric disorder from the disabilities that those disorders cause. In effect, the WHODAS score looks at the disability, assesses it, and then assesses what kind of impairments that disability causes in daily functioning of the affected individual.
So, what does the WHODAS look like? In WHODAS classifications, disorders result in particular impairments to function. The term disability covers not only impairments, but also activity limitations, participation restrictions, and the negative impact on a person’s interaction with his environment. The new test takes into account personal factors of a person rather than trying to fit everyone into broad categories. The WHODAS uses the International Classification of Functioning to assess social factors related to the individual’s functioning. This includes personal circumstances (age, education and motivation) as well as the individual’s environment. The individual’s environment is not limited to just the physical aspects, but also takes note of accommodations and support available.
WHODAS, unlike GAF, recognizes that two individuals can have the same disorder and the same functional impairments, but different degrees of disability due to personal and environmental factors. WHODAS is based on the model of diseases in which the assessment of impairment and disability is separate from the diagnosis of the disease. The actual test for WHODAS 2.0 is a self-report of assessment by the patient which evaluates six domains and the patient’s ability to perform in each of those domains over the last 30 days. They are as follows:
- Understanding and Communicating
- Getting Around (mobility)
- Self-care
- Getting along with people (social and interpersonal functioning)
- Life activities (home, academic, and occupational functioning)
- Participation in society (participation in family, social, and community activities).
The WHODAS 2.0 comes in two versions a 36- and a 12- question format. Each format is available in three versions: a self-administered, proxy-administered, and a rater-administered. (Proxy versions are meant for a third party, such as a caregiver to take, if the veteran is unable to complete the test himself.)
After completing the test, there are two scoring methods available, a simple scoring method and a complex scoring method. The simple scoring is done by hand and gives no weight to individual items, nor does it convert to a standardized scale. The complex method requires a computer to score and is based on an item-response theory. For rating purposes, this will likely be the version implemented by the VA to standardize scores.
The reason for the replacement of GAF with WHODAS is that the new test has been consistently shown to be reliable and responsive to change across different communities and geographic regions. WHODAS has demonstrated a good facial reliability across countries, populations and diagnostic groups including both ages and genders. For these reasons, the DSM-V has decided to remove GAF from its diagnostic toolbox and add the WHODAS 2.0.
In terms of rating disabilities, this does not mean that the GAF score that the VA has used for years is now useless in claims for disability. In fact, many decisions are still being argued on the basis of GAF scores, but there is a change coming. The change should mean more reliable and consistent ratings for veteran’s seeking help for their mental disorders. The change also means that there is going to be error as raters adjust to the new criteria, and it is therefore important to make sure that examiners are recording all symptoms and not just checking boxes on a sheet.
Look for further posts regarding how this change affects disability ratings as well as more explanation of how this new test works.
Thank you for your service.
