Special Article

Revising Axis V for DSM-IV:

A Review of Measures of Social Functioning

Howard H. Goldman, M.D., Ph.D., Andrew E. Skodol, M.D., and Tamara R. Lave, B.A.

Objective: Axis V, which uses the Global Assessment of Functioning Scale in the multiaxial
system ofDSM-III-R, is under review for DSM-IV. This article examines what is known about
axis V and selectively reviews the literature on measures ofsocial functioning to identify potential
alternatives to the Global Assessment of Functioning Scale. Method: About 25 studies on the
use, reliability, and validity ofaxis V in DSM-III and DSM-III-R are reviewed. In addition, nearly
30 measures of social functioning are reviewed and analyzed as potential substitutes for the
Global Assessment of Functioning Scale. The analysis focuses on the strengths and weaknesses
of each measure for assessing functioning on axis V. Results: Axis V measures are modestly
reliable and valid but not widely used. The authors identify and discuss two particular limitations
ofthe Global Assessment ofFunctioning Scale: 1) the combination ofmeasures ofsymptoms and
measures ofsocial functioning on a single axis and 2) the exclusion ofphysical impairments from
the rating of functioning. Conclusions: None of the measures of social functioning reviewed is
clearly superior to the Global Assessment of Functioning Scale for use on axis V. A modified
version of the Global Assessment of Functioning Scale, separating the measures of social and
occupational functioning from the measures of symptoms and psychological functioning, is pro-
posed for field testing, along with a new set of instructions permitting the rating of limitations
due to both physical and mental impairments.
(AmJ Psychiatry 1992; 149:1148-1156)

A V was introduced
“adaptive functioning”
in DSM-III
on a 7-point
as a measure
scale ranging
of for DSM-III-R
cording to DSM-III-R,
in an effort
axis
to increase
V, the Global
its utility.
Assessment
Ac-

from superior to grossly impaired. Axis V was modified of Functioning Scale, is to be used to assess “psycho-
logical, social, and occupational functioning.” It is
“available for use in special clinical and research set-
Received May 20, 1 991 ; revision received Dec. 1 8, 1 991 ; accepted tings” (DSM-III). It is not a required element of patient
Jan. 24, 1992. From the Department of Psychiatry, University of
evaluation and is regarded as a supplement to the “of-
Maryland School of Medicine; the Department of Psychiatry, Colum-
bia University College of Physicians and Surgeons, New York; and ficial” diagnoses (on axes I, II, and III). There is little
the New York State Psychiatric Institute, New York. Address reprint evidence concerning how frequently axis V is used for
requests to Dr. Goldman, Department of Psychiatry, University of planning treatment and predicting outcome (I).
Maryland School of Medicine, 645 West Redwood St., Baltimore, As a result of the revision of axis V in DSM-III-R, a
MD 21201.
simple measure of adaptive functioning was replaced by
The authors thank S.B. Fine, R.E. Gordon, J.S. Strauss, M.D. Tho-
mas, and H.S. Wilson for comments on earlier drafts of this article; a 90-point scale that combines assessments of psycho-
the other members of the Work Group on Multiaxial Issues (J.B. Wil- logical, social, and occupational functioning; it is based
hams, chairperson, A. Gruenberg, and J. Mezzich); and the work on the widely used Global Assessment Scale (GAS) (2).
group’s consultants and liaisons (A. Frances, HA. Pincus, D. Shaffer, It was thought that the Global Assessment of Function-
S. Sotterberg, R. Spitzer, and T. Widiger).
This article does not necessarily reflect the opinions of the American ing Scale would be a more useful element of the multi-
Psychiatric Association or the Task Force on DSM-IV. axial evaluation system than DSM-II1 axis V, because
Copyright © 1992 American Psychiatric Association. the GAS has been used in hundreds of studies and clini-

1148 Am] Psychiatry 149:9, September 1992

 GOLDMAN, SKODOL, AND LAVE

cal settings. There is little or no information, however, functioning, and patients with V codes, no axis I diag-
on the impact of the changes made for DSM-III-R on nosis, anxiety disorders, adjustment disorder, and ma-
the utility or acceptability of this supplementary axis. jor depression (single episode) received the best. In a
This report reviews what is known about axis V of sample of more than 10,000 patients, Mezzich et al.
DSM-III and DSM-III-R, reviews other measures of so- (10) found that depressed patients had higher axis V
cial functioning, and discusses several options for pro- ratings than nondepressed patients. Trzepacz et al. ( I I)
posed further revision of axis V for DSM-IV. found that liver transplantation candidates who were
delirious and who were seen by a consultation-liaison
service had lower axis V ratings than nondelirious pa-
RELIABILITY AND VALIDITY OF AXIS V tients. Westermeyer (12) reported lower levels of adap-
tive functioning among Asian refugees to the United
A number of published studies have addressed the re- States who had any axis I diagnosis than among those
liability or validity of DSM-III axis V. who had none, and Fabrega et al. (13) found a trend
toward greater impairment according to axis V at in-
Reliability take among patients whose axis I diagnoses were more
complex. These investigators found a highly significant
In the DSM-III field trials, the intraclass correlation relation between complexity of axis I disorder and defi-
coefficient (ICC) for axis V ratings of adult patients was cits in current functioning.
0.80 when the joint interview method was used and A sixth study, by Schrader et al. (1), had mixed re-
0.69 for test-retest evaluations (3). Fernando et al. (4) suits. These authors found no difference on axis V be-
reported a lower figure of 0.49 for the ratings of a mub- tween psychotic and nonpsychotic, psychotic and or-
tidisciplinary group of clinical workers on an inpatient ganic, or nonpsychotic and organic patient groups.
service. When psychotic patients were divided into those with
Russell et al. (5) found 64% agreement between affective psychoses and those with nonaffective psycho-
raters of cases of child psychopathology who used a ses, the former had higher levels of functioning than the
preliminary version of axis V consisting of a 4-point latter, who also had lower levels than patients with
scale of current impairment in adaptive functioning. nonpsychotic disorders. Bronheim et al. (14) reported
Using DSM-III axis V, Mezzich et al. (6) found an ICC that patients referred for psychiatric consultation from
of 0.61 for ratings of a mixed group of child and ado- an otolaryngology service had better functioning on
lescent cases. Rey et al. (7) reported an ICC of 0.57 for axis V than other referred patients.
a group of adolescents. All three of these studies had Three studies have examined the relation of axis V
clinicians rate written case summaries rather than the to other measures. Skodol et al. (9) compared axis V
patients in person. to measures of social and occupational functioning
Overall, reliability for axis V has been found to be included in the Psychiatric Epidemiology Research In-
higher than for axis IV. Given the relatively restricted terview (PERI) and other social network variables as-
diversity of clinicians, patients, information, and time sessed independently. They found significant correla-
frames in the published the demon-
studies, however, tions between axis V adaptive functioning and both
strated reliability of axis V has not been especially social and occupational variables, with occupational
good (8). Although special training in the use of the factors predominating. Westermeyer and Neider (15)
measures of functioning for axis V may improve reli- found highly significant negative correlations between
ability, we are not aware of any studies of the impact axis V ratings and two separate components of social
of training. networks-number of people and number of separate
social groups-among patients with substance abuse.
Validity Finally, Rey et al. (7) reported that in their samples of
adolescents, axis V functioned similarly to independ-
Most validity studies have compared adaptive func- ent ratings of premorbid functioning and less like
tioning as measured by axis V for different patient measures of social competence or present functioning.
groups identified by diagnosis or referral status. A few In a series of analyses, Gordon and associates have
have approached concurrent or construct validity by examined the relation between axis V ratings and treat-
comparing axis V ratings to other measures of adaptive ment status. Initially, Gordon et al. (16, 17) developed
functioning. The relation between axis V and disposi- a measure called the “strain ratio,” which is the ratio of
tion or treatment status studied,
has been mostly retro- axis IV ratings of severity of psychosocial stressors to
spectively. Two studies have used prospective designs axis V ratings, transformed in such a way that higher
to examine the predictive validity of axis V. ratings indicate better adaptive functioning. They found
Five studies have reported predictable diagnostic that length of inpatient hospitalization was correlated
group differences on axis V in diverse patient popula- with higher strain ratios: when patients’ rescaled levels
tions. In a mixed group of inpatients and outpatients, of functioning exceeded their scores on axis IV, they
Skodol et al. (9) found significant variation in axis V tended to remain in the hospital for a shorter period.
ratings across 10 diagnostic groups; patients with Subsequently, Gordon and Gordon ( 1 8) reported pre-
schizophrenia received the poorest ratings of adaptive dictable differences in axis V ratings between chroni-

Am J Psychiatry 149:9, September 1992 1149

REVISING AXIS V FOR DSM-IV

cabby ill state hospital patients, long-term inpatients, Beiser Ct al. (21) believed that the inclusion of symp-
short-term inpatients, and outpatients. toms in DSM-III-R axis V would undermine its ability
Mezzich et al. ( 1 9) found that ratings of highest level to discriminate schizophreniform from schizophrenic
of adaptive functioning in the past year correlated 0.27 patients. Gordon et al. (22) showed that symptom im-
with the decision to admit a patient for inpatient treat- provement and functional improvement, as measured
ment from a walk-in clinic. These investigators found a by axis V, did not go hand in hand in discharged pa-
greater correlation (r=0.45) between impairment in cur- tients followed in outpatient treatment over time. And
rent adaptive functioning, measured over the preceding finally, Skodol et al. (23) demonstrated that symptoms
month, and inpatient disposition. had a larger effect on axis V ratings, in terms of ex-
In the first of two prospective studies of the ability of pbained variance, than adaptive functioning variables
axis V ratings to predict outcome, Meibsop et al. (20) and tended to detract from the latter’s significance. Al-
found a significant relation between preadmission though the effect of symptom measures on explained
adaptive functioning as measured by axis V and symp- variance may be taken as support for changing axis V
tomatic outcome at 6 months among inpatients. They into the Global Assessment of Functioning Scale, the
also found, however, an even greater relation between change also may make axis V more redundant with axis
outcome and functioning as measured by the self-report I diagnoses. If a major objective of a multiaxial ap-
Social Adjustment Scale. In the second study of predic- proach is the quasi-independent assessment of different
tive validity, Beiser et al. (21 ) found that axis V was a domains relevant to a comprehensive psychiatric diag-
powerful predictor of which patients who received a nosis, then explicit inclusion of symptoms in the axis V
diagnosis of schizophreniform disorder early in a psy- ratings would seem to defeat this purpose.
chotic episode would, in fact, recover within the 6
months stipulated by DSM-III and which ones would
not recover, necessitating a change in diagnosis to STRENGTHS AND WEAKNESSES OF AXIS V
schizophrenia.
This review suggests that axis V is a reasonably valid
DSM-III-R Axis V measure of adaptive functioning, limited in part by its
modest reliability. In addition, some problems have
There are no currently published studies on the been identified with the changes introduced at the time
Global Assessment of Functioning Scale of DSM-III-R, of the revision of DSM-III. For example, there is mixed
but a number of the reports we have mentioned and two evidence on the value of obtaining measures of func-
additional studies have some bearing on the changes in tioning during two time periods (i.e., past month and
the adaptive functioning construct in DSM-III-R. The past year). (As might be expected, the value seems to
two major changes in concept are 1 ) the provision for depend on the nature of the question being asked, sug-
rating both highest level of adaptive functioning in the gesting that assessments in both time periods have
past year and current functioning and 2) the inclusion merit. Consequently, there is no great pressure to change
of symptom severity, as well as indicators of social and axis V, again, to a rating of a single period.) Two other
occupational functioning, in the ratings. problems, however, are believed by some to limit the
With respect to the first change, Skodol et al. (9) utility of axis V in DSM-III-R. In particular, there is
found few differences between social and occupational concern that I ) the assessment of functioning is attrib-
functioning measured over the past year as compared uted to mental impairment alone and 2) one axis com-
to measured over the past month when these were cor- bines measures of psychological, social, and occupa-
related with axis V ratings of highest level of function- tional functioning. In the first instance, it may be
ing in the past year. Rey et al. (7) also found a greater impossible to disentangle the combined limitations im-
relation between axis V and independent ratings of pre- posed by mental and physical impairments; in the bat-
morbid, rather than present, functioning. The analyses ter, it may be too difficult to assess these distinct do-
of Fabrega et al. (13) and Mezzich et a!. (6), however, mains of functioning with a global measure.
point to the potential importance of current functional These problems may be related. The progenitor of the
impairment as a consideration in diagnosis and treat- Global Assessment of Functioning Scale, the GAS, was
ment planning. designed as a global measure of psychopathology, fo-
With respect to the second change, several different cusing heavily on current psychological functioning. As
groups have attempted to divide axis V into its compo- such, it was logical to focus on functioning related to
nent parts and examine each component separately. In mental disorders alone. When the global GAS approach
the study by Trzepacz et al. (1 1 ), separate ratings of is used more broadly, emphasizing social and occupa-
current occupational, family, and social functioning all tional functioning over the past year, it may be much
bore the same relation to delirious versus nondelirious more problematic to attribute functioning to a mental
diagnostic status as did the overall axis V rating. On the disorder alone. Furthermore, when the GAS model is
other hand, Mellsop et al. (20) observed some vari- used in general medical settings or with elderly patients
ations in the relation between three similar factors and who have multiple impairments, it is even more difficult
outcome prediction and suspected that global ratings of to make such attribution reliably (personal communi-
adaptive functioning masked significant variability. cation, E. Caine).

1150 Am J Psychiatry 149:9, September 1992

 GOLDMAN, SKODOL, AND LAVE

The combination on a single axis of measures of psy- Scale, Personal Adjustment and Role Skills Scale, Psy-
chological, occupational, and social functioning is chiatric Status Schedule, Psychiatric Evaluation Form,
problematic for two reasons: 1 ) it violates the principle and Current and Past Psychopathology Scales. This
of a multiaxial system in which each axis “refers to a group also includes symptoms, is somewhat more in-
different class of information” (DSM-III-R), and 2) it clusive of areas of functioning than group 1, and is
may also confuse raters because of the complexity of broadly applicable to the entire clinical population. It is
making a single rating which integrates three different similar to group 5, which includes the Social Behaviour
dimensions that do not always vary together. As we Assessment Schedule and the Self-Assessment Guide,
have noted, there is evidence from Skodol et al. (9, 23), both of which are more detailed measures of function-
supported by the findings of other studies (20-22), that ing than the instruments in group 2. Group 3 includes
ratings on axis V are highly correlated with those on the Rehabilitation Evaluation of Hall and Baker and the
axis I, indicating that axis V does not provide a suffi- Community Living Assessment Scale, which do not in-
ciently independent class of information. In addition, dude symptom measures, which focus on a narrow do-
other investigators (24-27) have indicated that psycho- main of functioning, and which principally apply to a
logical functioning often does not correlate well with limited population in 24-hour care. The Personal Re-
social and occupational functioning. Although a recent sources Inventory and Interview Schedule for Social In-
set of studies by Liberman (28) suggest a significant re- teraction are in group 4; they do not include symptom
lation between symptom measures and occupational measures, and they focus on a narrow range of func-
functioning, it is a relationship mediated by functional tioning but are more broadly applicable than the instru-
impairments in the
to work capacity
(such as limita- ments in group 3.
tions in social interaction and activities of daily living). Groups 6 and 7 are similar. All of the instruments
Before deciding to recommend retaining the Global (Community Adaptation Schedule, Structured and Scaled
Assessment of Functioning Scale for axis V or changing Interview to Assess Maladj ustment, Standardized Inter-
to another measure, we turned again to the literature. view to Assess Social Maladjustment, Community Ad-
justment Profile System, Social Stress and Functioning
Inventory for Psychotic Disorders, Social Functioning
MEASURES OF SOCIAL FUNCTIONING Schedule, and the various versions of the Social Adjust-
ment Scale) measure a broad range of functioning with-
We reviewed the literature on measures of social out assessing symptoms. The social functioning scales
functioning in an effort to find out what other measures from the PERI (27) and the Longitudinal Interval Fob-
might be used as models for axis V. Our review relied bow-up Evaluation (56) were not included in either re-
heavily on two articles: “The Assessment of Social Ad- view and should be added to category 7. The same is
justment: An Update” by Weissman et al. (29) and true for the Role Activity Performance Scale (57). All
“Functional Assessment in Rehabilitation” by Wallace are applicable to a broad population, and almost all
(30). Promising instruments were viewed in more detail give global ratings, but the Community Adaptation
from their original sources. Although we reviewed each Schedule is judged by Wallace (30) to have limited in-
of the instruments for depth and breadth of measures, formation on its psychometric properties.
appropriate target population, and psychometric prop- We refer the interested reader to the two review arti-
erties, the special criteria we used to evaluate these des and the original material in the literature for a more
scales for possible inclusion in axis V focused also on comprehensive assessment of these instruments. Our
simplicity ( “user friendliness”) and unidimensionality brief review focuses on the suitability of alternatives to
(i.e., involving a single class of information). The in- the Global Assessment of Functioning Scale for inclu-
struments reviewed in the articles by Weissman et al. sion in DSM-IV.
and Wallace are shown in table 1 ; citations of the origi- Given our criteria of unidimensionality, the instruments
nal references are provided. The reviews of each of in groups 3, 4, 6, and 7 should be considered as alterna-
these instruments are summarized in table 1 along sev- tives to the Global Assessment of Functioning Scale.
eral dimensions, including psychometric properties and Groups 3 and 4, however, cover too limited a domain of
method of scoring. Each instrument is placed into one functioning, and group 4 is also limited in its applicability.
of seven groups on the basis of inclusion of symptoms The Community Adaptation Schedule (group 6) also
in the instrument or schedule, depth and breadth of di- might be eliminated because oflimited psychometric data,
mensions of functioning, and applicability to the gen- leaving the instruments in group 7. If the criterion of uni-
eral population (rather than to a specific clinical group). dimensionality is deemphasized, then groups 1, 2, and S
As shown in table 1, group 1 consists of the Denver also must be considered. Group I is a weaker choice be-
Community Mental Health Questionnaire and the cause ofbimitations in range offunctioning measured and
KDS-1S Marital Questionnaire, which include symp- applicability, as well as lack of a global measure. Groups
tom measures, do not include role performance meas- 2 and S include many meritorious measures of symptoms
ures (especially the Denver Community Mental Health and functioning. In fact, the GAS, the basis for the Global
Q uestionnaire), and focus on specific clinical groups Assessment ofFunctioning Scale, is derived from the work
(i.e., community mental health clinic clients and mar- of some of the same investigators who developed the in-
ried couples). Group 2 includes the Katz Adjustment struments in group 2.

Am J Psychiatry 1 49:9, September 1992 1151

REVISING AXIS V FOR DSM-IV

In terms of user friendliness, global ratings are given TABLE 1. Measures of Social Adjustment and Functioning
by instruments in groups 2, 3, 6, and 7. All of these Inclusion of
ratings, however, are based on fairly extensive inter- Instrument Symptoms
view schedules or structured self-reports. In part, their
Group I Yes
structured formats make them reliable and recommend
them for use in research. On the other hand, none of Denver Community Mental Health
these measures could be regarded as simple enough for Questionnaire (DCMHQ) (31, 32)
KDS-15 Marital Questionnaire (KDS-15) (33)
routine use in clinical practice.
Group 2 Yes

OPTIONS Katz Adjustment Scale (KAS) (34)

Personal Adjustment and Role Skills Scale

The approach to change for DSM-IV has been char-
(PARS) (35)
acterized as “conservative,” requiring compelling ar- Psychiatric Status Schedule (PSS) (36)
guments and extensive documentation to support al-
terations in the nosobogy (58). Although our review Psychiatric Evaluation Form (PEF) (37)
suggests a number of problems with the current Global
Current and Past Psychopathology Scales
Assessment of Functioning Scale, there are problems (CAPP’ (381
with all of the potential alternatives as well. Before Group 3 No
considering a complete change in axis V, there should
be evidence of severe problems with the Global Assess- Rehabilitation Evaluation of Hall and Baker
(REHAB) (39)
ment of Functioning Scale and/or an outstanding new
alternative. Considerable experience with the Global Community Living Assessment Scale (CLAS)
Assessment of Functioning Scale (and its predecessor, (40)
the GAS) and its apparent simplicity made it a choice

for DSM-III-R and argue for its retention-with some Group4 No

significant modification. As we have noted, the princi- Personal Resources Inventory (PR!) (4 1)
pal limitations of the Global Assessment of Function-
ing Scale are I ) the combination of ratings of symp- Interview Schedule for Social Interaction (ISSI)
toms and functioning on a single scale and 2) the rating (42, 43)
Group S Yes
of functioning based on mental impairment alone
rather than the combined effect of mental and physical Social Behaviour Assessment Schedule (SBAS)
impairments. (44)
The Global Assessment of Functioning Scale could be Self-Assessment Guide (SAG) (45)
modified to separate the rating of symptoms and psy- Group 6
Community Adaptation Schedule (CAS) (46) No
chological functioning from the rating of social and oc-
cupational functioning. We propose a field test of a
modification of the current axis V scale. (See appendix Group 7 No (except
1 for an example of one modification.) We have divided SSIAM)
Structured and Scaled Interview to Assess
the current Global Assessment of Functioning Scale
Maladjustment (551AM) (47, 48)
into two separate scales, one to measure global symp- Standardized Interview to Assess Social
tomatobogy and psychological functioning, the other to Maladjustment (SIASM) (49, 50)
measure social and occupational functioning. The Community Adjustment Profile System
modified scale in appendix 1 retains the same scale (CAPS) (51)
Social Stress and Functioning Inventory for
points and many of the anchoring descriptors that are
Psychotic Disorders (SSFIPD) (52)
used in the current Global Assessment of Functioning Social Functioning Schedule (53)
Scale. We hypothesize that this change will reduce con- Social Adjustment Scale (SAS); Self-Report
fusion and improve the independence of the ratings of (SAS-SR); Version II (SAS-Il) (54, 55)
these domains. This hypothesis, as well as the reliability
of the measures, should be assessed in a field trial of the
modified scale. The results of the field trial may indicate
a need for more elaborate anchoring descriptors, which The modified scale’s measure of social and occupa-
could then be developed. If it is found that the modified tional functioning is similar conceptually to the original
Global Assessment of Functioning Scale shown in ap- DSM-III axis V measure of adaptive functioning. The
pendix I is more reliable, produces ratings on social modified scale’s measure of global symptomatobogy
and occupational functioning that are significantly and psychological functioning would be a new assess-
more independent of axis I than the current scale rat- ment. It might be included as a second rating on axis V
ings, and is more acceptable to clinicians who use it in or rated on a separate axis. It is likely that ratings on
the field trial, then the modified scale should be used as this measure will be highly correlated with axis I. To
a substitute for the current scale. some extent it also may be redundant with the proposed

1 152 Am J Psychiatry 1 49:9, September 1992

 GOLDMAN, SKODOL, AND LAVE

TABLE 1 (continued)
Psychometric
Depth Scoring Applicability Characteristics Other Characteristics

Not much depth Give specific and more Highly specific Reliable and valid
general scores
Little attention to role Designed only for
performance mental patients
Looks only at marriage Designed only for
married couples
Not much depth Give specific and more Generally Reliable and valid
general scores applicable
Ignores many roles; does not Short and simple; can be used with
discuss cause of problems significant other
Gives global rating

Does not discuss cause of Gives global rating Flexible; includes probes; can be used
problems with significant other
Does not discuss cause of Gives global rating
problems
Does not discuss cause of Gives global rating
problems
Not much depth Give specific and more Highly specific Reliable and valid
general scores
Gives global rating Designed only for Well explained; simple to use; easy to
institutionalized interpret
patients
Designed for mdi- Should be further
viduals in residen- investigated
tial care facility
Not much detail; look only at Give specific and more Generally Reliable and valid
individual’s support network general scores applicable
Should be further
investigated

Very detailed Give specific and more Generally Reliable and valid
general scores applicable

Self-report; short

Very detailed Gives specific and more Generally Reliability and va- Self-report
general scores; also applicable lidity need fur-
gives a global rating ther investigation
Very detailed Give specific and more Generally Reliable and valid
general scores applicable
Careful about interviewer bias; can
be used with significant other
Gives a global rating Can be used with significant other

For significant other

Can be used with significant other

Gives a global rating Flexible; can be given to significant

other; self-report available; good
with psychotic patients

inclusion of severity ratings for each mental disorder A simple modification in the instructions for rating the
(personal communication, J Mezzich). . Global Assessment of Functioning Scale could address the
The instruments in group 7 should be examined further other identified problem with axis V. As we have noted,
as potential substitutes in the future, especially ifthere are when assessing certain patients, it is difficult (or impossi-
problems with the Global Assessment of Functioning ble) to separate the effects of mental impairments from
Scale or its modification. If warranted by further exami- physical impairments contributing to limitations in social
nation, there should be a field trial ofthe bestgbobal meas- and occupational functioning. Axis V in DSM-III did not
ure or measures from group 7 for use in general clinical instruct the rater to make any such distinction. In contrast,
practice without a standardized schedule. the instructions for the Global Assessment of Functioning

Am J Psychiatry 1 49:9, September 1992 1153

REVISING AXIS V FOR DSM-IV

Scale explicitly call for a rating of limitations of function- 3. Spitzer RL, Forman JBW: DSM-III field trials, II: initial experi-

ing due to mental impairments alone. We propose a field ence with the multiaxial system. Am J Psychiatry
136: 1979;
818-820
test of a modification of the instructions for the modified 4. Fernando T, Mellsop G, Nelson K, Peace K, Wilson J: The reli-
Global Assessment of Functioning Scale (Functioning) to ability of axis V of DSM-I!I. Am J Psychiatry I 986; 143:752-755
assess social and occupational functioning due to the com- S. Russell AT, Cantwell DP, Mattison R, Will L: A comparison of
bined effects of mental and nonmental medical impair- DSM-II and DSM-III in the diagnosis of childhood psychiatric

ments (appendix I). disorders: multiaxial features. Arch Gen Psychiatry 1979; 36:
1223-1226
6. Mezzich AC, Mezzich JE, Coffman GA: Reliability of DSM-III
vs DSM-II in child psychopathology. J Am Acad Child Psychia-
CONCLUSIONS try 1985; 24:273-280
7. Rey JM, Stewart GW, Plapp JM, Bashir MR, Richards IN: Va-
The options under consideration by the Work Group lidity of axis V of DSM-III and other measures of adaptive func-
tioning. Acta Psychiatr Scand 1988; 77:534-542
on Multiaxial Issues include some combination of changes 8. Rey jM, Plapp JM, Stewart G, Richards I, Bashir M: Reliability
in the basic structure of the Global Assessment of Func- ofthe psychosocial axes ofDSM-III in an adolescent population.
tioning Scale and in the instructions. Our review of the BrJ Psychiatry 1987; 150:228-234
relevant literature suggests both of these potential modi- 9. Skodol AE, Link BG, Shrout PE, Horwath E: Toward construct
validity for DSM-III axis V. Psychiatry Res 1988; 24:13-23
fications, following a conservative strategy for change.
10. Mezzich JE, Fabrega H Jr, Coffman GA: Multiaxial charac-
The final decision should be based on a field test of these terization of depressive patients. J Nerv Ment Dis 1 987; 175:
recommendations. It is our hope that these modest 339-345
changes will increase the utility and use of axis V. 11. Trzepacz PT, Brenner R, Van Thiel DH: A psychiatric study of
247 liver transplantation candidates. Psychosomatics 1 989; 30:
In following a less conservative strategy for change,
147-153
several other avenues of research and scale develop- 12. Westermeyer J: DSM-III psychiatric disorders among Hmong
ment are indicated. First, there is a need to study the refugees in the United States: a point prevalence study. Am J Psy-
impact of various approaches to training on the reliabil- chiatry 1988; 145:197-202
ity of measures of social and occupational functioning. 13. Fabrega HJr, Pilkonis P, MezzichJ, Ahn CW, Shea S: Explaining
diagnostic complexity in an intake setting. Compr Psychiatry
Second, our review suggests the need for different meas-
1990; 31:5-14
ures for different areas of functioning. The conservative
14. Bronheim H, Strain JJ, Biller HF, Fulop G: Psychiatric consulta-
strategy and requirement for simplicity, applicable to tion on an otolaryngology service. Gen Hospital Psychiatry
multiaxial diagnosis and DSM, may be overly limiting 1989; 11:95-102
for valid and useful measurements of functioning. A is. Westermeyer J, Neider J: Social networks and psychopathol-
more multidimensional approach to measuring social ogy among substance abusers. Am J Psychiatry 1988; 145:1265-
1269
and occupational functioning in individuals with men-
16. Gordon RE, Jardiolin P, Gordon KK: Predicting length of hospi-
tab disorders may be superior. The research literature tal stay of psychiatric patients. Am J Psychiatry 1985; 142:235-
suggests numerous more complex measures. Further in- 237
vestigation may produce simpler measures of each of 17. Gordon RE, VijayJ, Sloate SG, Burket R, Gordon KK: Aggravat-
the multiple dimensions of functioning that could be ing stress and functional level as predictors of length of psychi-
atric hospitalization. Hosp Community Psychiatry 1985; 36:
used in practice as well as research.
773-774
Leaders in general medicine have called for the use of 18. Gordon RE, Gordon KK: Relating axes IV and V of DSM-III to
simple measures of functioning in routine clinical prac- clinical severity of psychiatric disorders. Can J Psychiatry 1987;
tice-to support the need for measures of clinical out- 32:423-424
come (59-61). Feinstein et al. (62) warned of the prob- 19. MezzichJE, Evanczuk KJ, Mathias Ri, Coffman GA: Admission
decisions and multiaxial diagnosis. Arch Gen Psychiatry 1984;
lems associated with these needed measures, noting that
41:1001-1004
the measures should be “sensible” as well as reliable and 20. Mellsop G, Peace K, Fernando T: Pre-admission adaptive func-
valid. The current Medical Outcomes Study (61) has been tioning as a measure of prognosis in psychiatric inpatients. Aust
using a “short form” measure of several dimensions of NZJ Psychiatry 1987; 21:539-544
functioning and health status (63) and has adapted it 21. Beiser M, Fleming JAE, lacono WG, Lin T: Refining the diagno-
sis of schizophreniform disorder. Am J Psychiatry I 988; 145:
for use in assessing outcomes in a variety of clinical con-
695-700
ditions, including depression (64, 65). The field of psy- 22. Gordon RE, Plutzky M, Gordon KK, Guerra M: Using the axis
chiatry has growing experience with functional assess- V scale to evaluate therapeutic outcome of psychiatric treatment.
ment and the measurement of medical outcomes. We CanJ Psychiatry 1988; 33:194-196
have the opportunity to be in the forefront of this im- 23. Skodol AE, Link BG, Shrout PE, Horwath E: The revision of axis
V in DSM-III-R: should symptoms have been included? Am J
portant area of health care research and practice.
Psychiatry 1988; 145:825-829
24. Anthony WA, Cohen BF: Functional assessment in psychiatric
rehabilitation, in Functional Assessment in Rehabilitation. Ed-
REFERENCES ited by Halpern A, Fuhrer
M. Baltimore, Brookes, 1984
25. Strauss JS, Carpenter WT Jr: Prediction of outcome in schizo-
1. Schrader G, Gordon M, Harcourt R: The usefulness of DSM-III phrenia, II: relationships between predictor and outcome van-
axis IV and axis V assessments. AmJ Psychiatry 1986; 143:904- ables: a report from the WHO International Pilot Study of
907 Schizophrenia. Arch Gen Psychiatry I 974; 31:37-42
2. EndicottJ, Spitzer RL, Fleiss JL, CohenJ: The Global Assessment 26. Strauss JS, Carpenter WT Jr: Prediction of outcome in schizo-
Scale: a procedure for measuring overall severity of psychiatric phrenia, III: five-year outcome and its predictors. Arch Gen Psy-
disturbance. Arch Gen Psychiatry 1976; 33:766-771 chiatry 1977; 34:159-1 63

1 1S4 AmJ Psychiatry 149:9, September 1992

 GOLDMAN, SKODOL, AND LAVE

27. Dohnenwend BS, Dohrenwend BP, Link B, Levav I: Social func- 49. Clare AW, Cairns VE: Design development and use of a stand-
tioning of psychiatric patients in contrast with community cases ardized interview to assess social maladjustment and dysfunction
in the general population. Arch Gen Psychiatry 1983; 40:1174- in community studies. Psychol Med 1978; 8:589-604
I I82 so. Clare AW, Cairns YE: A Manual for Use in Conjunction With
28. Liberman RP: Psychiatric Symptoms and the Functional Capac- the General Practice Research Unit’s Standardized Social Inter-
ity to Work: Final Report, Research Grant (Social Security Ad- view Schedule. London, Institute of Psychiatry, 1979
ministration) 10-P-98193. Los Angeles, UCLA, Department of SI. Evenson RC, Sletten 1W, Hedlund JL, Faintich DM: CAPS: an
Psychiatry, and Brentwood VA Medical Center, 1990 automated evaluation system. Am J Psychiatry 1974; 13 1:531-
29. Weissman MM, Sholomskas D, John K: The assessment of so- 534
cial adjustment: an update. Arch Gen Psychiatry 1981; 38:1250- 52. Serban G: Social Stress and Functioning Inventory for Psychotic
1258 Disorders (SSFIPD): measurement and prediction of schizo-
30. Wallace Ci: Functional assessment in rehabilitation. Schizophr phrenics’ community adjustment. Compr Psychiatry I 978; 19:
Bull 1986; 12:604-624 337-347
31. Ciarlo JA, Reihman J: The Denver Community Health Question- 53. Remington M, Tyrer P: The Social Functioning Schedule-a brief
name: development of a multi-dimensional program evaluation semi-structured interview. Social Psychiatry 1979; 14:151-157
instrument, in Program Evaluation for Mental Health: Methods, 54. Weissman M, Bothwell 5: Assessment of social adjustment by
Strategies, and Participants. Edited by Coursey R, Spector G, patient self-report. Arch Gen Psychiatry 1976; 33:1111-1115
Murrell S, Hunt B. New York, Grune & Stratton, 1977 55. Schooler N, Hogarty G, Weissman MM: Social Adjustment Scale
32. Ciarlo JA, Reihman J: The Denver Community Mental Health II (SAS-Il), in Resource Materials for Community Health Pro-
Q uestionnaire: Development of a Multi-Dimensional Program gram Evaluators: Publication ADM 79-328. Edited by Har-
Evaluation Instrument. Denver, Northwest Denver Mental greaves WA, Attkisson CC, Sorenson JE. Washington, DC, US
Health Center and the University of Denver, 1975 Department of Health, Education, and Welfare, 1979
33. Kupfer D, Frank E: The KDS-1S: A Marital Questionnaire. Pitts- 56. Keller M, Lavori P, Friedman B, Nielsen E, Endicott J, McDon-
burgh, Western Psychiatric Institute and Clinic, University of ald-Scott P, Andreasen N: The Longitudinal Interval Follow-up
Pittsburgh, 1974 Evaluation. Arch Gen Psychiatry I 987; 44:540-548
34. Katz MM, Lyerly SB: Methods for measuring adjustment and 57. Good-Ellis M, Fine 5, Spencer J, DiVittis A: Developing a role
social behavior in the community, I: rationale, description, dis- activity performance scale. Am J Occupational Therapy 1987;
criminative validity and scale development. Psychol Rep 1963; 41:232-241
I 3:503-535 58. Frances A, Pincus HA, Widiger TA, Davis WW, First MB: DSM-
35. Ellsworth RB, Foster L, Childers B, Arthur G, Kroeker D: Hos- IV: work in progress. Am J Psychiatry 1990; 147:1439-1448
pital and community adjustment as perceived by psychiatric pa- 59. Schroeder SA: Outcome assessment 70 years later: are we ready?
tients, their families, and staff. J Consult Clin Psychol 1968; 32: (editorial). N Engl J Med 1987; 316:160-1 62
1-41 60. Ellwood P: Shattuck lecture: outcomes management. N Engl J
36. Spitzer RL, Endicott J, Fleiss J, Cohen J: The Psychiatric Status Med 1988; 318:1549-1 556
Schedule: a technique for evaluating psychopathology and im- 61. Tarlov AR, Ware JE Jr, Greenfield 5, Nelson EC, Perrin E, Zub-
pairment in role functioning. Arch Gen Psychiatry 1970; 23:4 1- koff M: The Medical Outcomes Study: an application of methods
55 for monitoring the results of medical care. JAMA 1989; 262:
37. Endicott J, Spitzer RL: What! another rating scale? the Psychiat- 925-930
nc Evaluation Form. J Nerv Ment Dis 1972; 154:88-104 62. Feinstein A, Josephy B, Wells C: Scientific and clinical problems
38. EndicottJ, Spitzer RL: Current and Past Psychopathology Scales in indexes of functional disability. Ann Intern Med 1986; 105:
(CAPPS): rationale, reliability, and validity. Arch Gen Psychiatry 413-420
1972; 27:678-687 63. Stewart A, Hays R, WareJ: The MOS short-form General Health
39. Baker R, Hall JM: Rehabilitation Evaluation of Hall and Baker Survey. Med Care I 988; 26:724-735
(REHAB). Aberdeen, Scotland, Vine, 1983 64. Stewart A, Greenfield 5, Hays R, Wells K, Rogers W, Berry 5,
40. WilIer BS, Gustafero JR: Development of a computer-assisted re- McGlynn E, Ware J: Functional status and well-being of patients
with chronic conditions. JAMA 1989; 262:907-913
cord for psychiatry, in Goal Attainment Review, vol 1 . Edited by
65. Wells K, Stewart A, Hays R, Burnham A, Rogers W, Daniels M,
Garwick G. Minneapolis, Program Evaluation Resource Center,
Berry 5, Greenfield 5, Ware J: The functioning and well-being of
1974
depressed patients. JAMA 1989; 262:914-919
41. Clayton P, Hirschfeld R: Personal Resources Inventory (PRI). St
Louis, Washington University School of Medicine, 1977
42. Duncan-Jones P, Henderson 5: Interview Schedule for Social In-
APPENDIX 1. Modification of the Global Assessment of Function-
teraction (1551), 10th ed. Canberra, Australian National Univer-
ing Scale: Mental and Physical Impairments Functioning Scale
sity, Social Psychiatry Research Unit, 1978
(GAFS-M)
43. Henderson 5, Duncan-Jones P, Byrne DG, Scott R: Measuring
social relationships: the Interview Schedule for Social Interac-
tion. Psychol Med I 980; 10:723-734 Consider social and occupational functioning on a hypo-
44. Platt 5, Weyman A, Hirsch 5, Hewett 5: The Social Behaviour thetical continuum of mental health-illness. Include impair-
Assessment Schedule (SBAS): rationale, contents, scoring, and ment in functioning due to physical limitations as well as
reliability of a new interview schedule. Social Psychiatry 1980; mental impairments. Use HIGHEST LEVEL OF FUNC-
15:43-55 TIONING IN PAST YEAR (i.e., highest level of functioning
45. WilIer B, Biggen P: Comparison of rehospitalized and nonrehos- for at least a few months during the past year).
pitalized psychiatric patients on community adjustment: Self-As-
sessment Guide. Psychiatry 1976; 39:239-244
46. Burnes AJ, Rosen SR: Social roles and adaptation to the commu- Code
nity. Community Ment Health J 1967; 3:153-158
47. Gurland BJ, Yorkston NJ, Stone AR, Frank JD, Fleiss JL: The 9 Good functioning in all areas, interested and involved
Structured and Scaled Interview to Assess Maladjustment
81 in a wide range of activities, socially effective
(551AM), I: description, rationale, and development. Arch Gen
Psychiatry I 972; 27:259-264
48. Gurland BJ, Yorkston NJ, Goldberg K, Fleiss JL, Sloane RB, 80 No more than slight impairment in social and occu-
Cnistol AH: The Structured and Scaled Interview to Assess Mal- pational functioning (e.g., missing a few deadlines or
adjustment (551AM), II: factor analysis, reliability, and validity. appointments) or school functioning (e.g., temporar-
Arch Gen Psychiatry 1972; 27:264-267 71 ily falling behind in school work)

AmJ Psychiatry 149:9, September 1992 1155

REVISING AXIS V FOR DSM-IV

70 Some difficulty in social or occupational functioning 40 Major impairment in several areas, such as work or
(e.g., frequent work absences, work occasionally in- school, family relations, judgment (e.g., avoids
complete or judged “not up to standards”) or school friends, neglects family, is unable to work; child fre-
functioning (e.g., occasional truancy, or theft within 31 quently beats up younger children, is failing at school)
the household) but generally functioning pretty well;
61 has some meaningful interpersonal relationships 3 Inability to function in almost all areas (e.g., stays in
21 bed all day; no job, home, or friends)

60 Moderate difficulty in social, occupational, or school 20 Occasionally fails to maintain minimal personal hy-
functioning (e.g., few friends, conflicts with co-work- giene (e.g., smears feces); unable to function inde-
ers, unable to complete work assignments, unsatisfac- 1 1 pendently
SI tory work performance)
10 Persistent inability to maintain minimal personal hy-
SO Serious impairment in social, occupational, or school giene; unable to function without harming self or oth-
functioning (e.g., no friends, unable to keep a job at ers or without considerable external support (e.g.,
41 expected or prior level of performance) 01 nursing care and supervision)

1156 Am J Psychiatry 149:9, September 1992