NEUROPSYCHIATRY (September 2008) Symptoms 7 Point Scale

UST Faculty of Medicine and Surgery Somatic concern 0 - Not Assessed

PSYCHIATRIC RATING SCALES Anxiety 1 - Not Present
Lecturer: Raymond L. Rosales, M.D. PhD, FPNA, FPPA Depression 2 - Very Mild
(with added notes from previous batch) Suicidality 3 - Mild
Guilt 4 - Moderate
Hostility 5 - Moderately Severe
PSYCHIATRIC RATING SCALES Elated Mood 6 - Severe
• Rating Instruments Grandiosity 7 - Extremely severe
• Provide a way to quantify aspects of a patient’s psyche, Suspiciousness
behavior and relationships with individuals and society Hallucinations
• Clinicians who do not use rating scales are left only with Unusual thought content
clinical impressions Bizarre behaviour
Self-neglect
CHARACTERISTICS OF RATING SCALES Disorientation
1. can be specific or comprehensive Conceptual disorganisation
2. can measure internally experienced variable (eg. mood) Blunted affect
3. can measure externally observable variable (eg. behavior) Emotional withdrawal
4. assess classic items from the mental status examination Motor retardation
5. assessment of adverse effects from psychotherapeutic drugs; Tension
social adjustments and psychoanalytic concepts Uncooperativeness
Excitement
OTHER CHARACTERISTICS Distractibility
1. time covered Motor hyperactivity
2. level of judgement required Mannerisms and posturing
3. method of recording answers
a. dichotomous variable (eg. true or false, present or absent) A.2. PANSS RATING MANUAL(Positive and negative symptom
b. continuos variable (eg. severity, frequency) scale)
Background
PSYCHIATRIC RATING SCALES • developed and standardized for typological and dimensional
A. Rating scales used for Schizophrenia of Psychosis assessment of schizophrenic phenomena
B. Rating scales used for Mood disorders • 33 items, 7 point rating
C. Rating scales used for Anxiety disorders • Evaluates positive, negative and other symptom dimensions
D. Others: on the basis of a formal semi-structured clinical interview and
1. Child/adolescent patients other informational sources.
2. Adverse effects of drugs • Domains
3. Quality of life Positive Scale General Psychopathology
4. Dissociative disorders Negative Scale Supplemental Aggression Risk
Composite
A. Rating Scales in Schizophrenia of Psychosis • Adaptation of the BPRS and the Psychopathology rating
1. Brief Psychiatric Rating Scale (BPRS) schedule
2. Positive and negative symptom scale (PANSS) • Positive – 7 items
3. Schedule for Affective Disorders and Schizophrenia (SADS) • Negative – 7 items
4. Scale for the Assessment of Negative Symptoms (SANS) • Composite – difference between Positive and Negative
5. Scale for Assessment of Positive Symptoms (SAPS) symptoms
6. Scale for the Assessment of Thought, Language and • General Psychopathology - 16
Communication (TLC)
7. Thought Disorder Index (TDI)
8. Quality of Life Scale (QLS)
9. Chestnut Lodge Prognostic Scale for Chronic Schizophrenia

B. Rating Scales in Affective Disorders

1. Young Mania Rating Scale – for Bipolar Disorder
2. Hamilton Rating Scale for Depression (HAM-D)
3. Montgomery-Asberg Depression Rating Scale (MADRS)
4. Becks Depression Inventory
5. Standard Assessment of Depressive Disorder (SADD)
6. Zung Self-rating Scale for Depression
7. Caroll Rating Scale for Depression
8. Raskin Depression Rating Scale
9. Inventory to Diagnose Depression
10. Mania State Rating Scale

C. Rating Scales used for Anxiety disorders

1. Hamilton A rating scale for Anxiety (HAM – A)
2. Acute Panic Inventory
3. Covi Anxiety Scale
4. Anxiety States Inventory
5. Yale Brown Obsessive Compulsive Scale
6. Brief Outpatient Psychopathology Scale Instructions: For each item below (P1, P2, etc.) enter the code that
7. Physician's Questionnaire best describes the patient’s psychopathology.
8. Fear Questionnaire
9. Mobility Inventory For Agoraphobia POSITIVE SCALE
10. Social Avoidance and Distress Scale
11. Leyton Obsessional Inventory P1 DELUSIONS: Beliefs which are unfounded, unrealistic, and
12. Fear Thermometer idiosyncratic.
13. Impact of Events Scale Basis for rating: thought content expressed in the interview and its
influence on social relations and behavior.
Rating Scales for Functioning
1. Social Occupational Functioning Assessment Scale (SOFAS) 1 = Absent – Definition does not apply.
2. Global Assessment of Relational Functioning (GARF) 2 = Minimal – Questionable pathology; may be at the upper extreme of
normal limits
A.1. Brief Psychiatric Rating Scale (BPRS) 3 = Mild – Presence of one or two delusions which are vague,
• Administered by: Psychiatrists, psychologists or other trained uncrystallized and not tenaciously held. Delusions do not interfere with
rater thinking, social relations or behavior.
• Time to complete: 15-30 minutes 4 = Moderate – Presence of either a kaleidoscopic array of poorly
• 18-item scale measuring positive symptoms, general formed, unstable delusions or a few well-formed delusions that
psychopathology and affective symptoms. occasionally interfere with thinking, social relations or behavior
• When rating BPRS, it is important to allow unstructured 5 = Moderate Severe – Presence of numerous well-formed delusions
sections in the clinical interview such that conceptual that are tenaciously held and occasionally interfere with thinking, social
disorganization in the patient's thought and speech and relations or behavior.
unusual thought content can be observed. 6 = Severe – Presence of stable set of delusions which are crystallized,
• Each item is rated on a seven-point scale (1=not present to possibly systematized, tenaciously held, and clearly interfere with
7=extremely severe) thinking, social relations and behavior
7 = Extreme – Presence of stable set of delusions which are either YMRS 7: Language/Thought Disorder
highly systematized or very numerous and which dominate major facets 0 = Absent.
of the patient’s life. This frequently results in inappropriate and 1 = Circumstantial; mild distractibility; quick thoughts.
irresponsible action, which may even jeopardize the safety of the patient 2 = Distractible: loses goal of thoughts; changes topic frequently;
or others. racing thoughts.
3 = Flight of ideas; tangentiality; difficult to follow; rhyming; echolalia.
P2 CONCEPTUAL DISORGANIZATION: Disorganized process of 4 = Incoherent; communication impossible.
thinking characterized by the disruption of goal-directed sequencing,
(e.g., circumstantiality, tangentiality, loose associations, non sequiturs, YMRS 8: Content
gross illogicality, or thought block). 0 = Normal.
Basis for rating: cognitive-verbal processes observed during the 2 = Questionable plans, new interests.
course of the interview. 4 = Special project(s), Hyper-religious.
6 = Grandiose or paranoid ideas (inappropriate); ideas of reference.
1 = Absent – Definition does not apply. 8 = Delusions, hallucinations.
2 = Minimal – Questionable pathology; may be at the the upper extreme
of normal limits. YMRS 9: Disruptive-Aggressive Behavior
3 = Mild – Thinking is circumstantial, tangential, or paralogical. There is 0 = Absent, cooperative.
some difficulty in directing thoughts toward a goal, and some loosening 2 = Sarcastic; loud at times, guarded.
of associations may be evidenced under pressure. 4 = Demanding; threats on ward (or usual environment).
4 = Moderate – Able to focus thoughts when communications are brief 6 = Threatens interviewer; shouting (during interview); interview difficult.
and structured, but becomes loose or irrelevant when dealing with more 8 = Assaultive; destructive, interview impossible.
complex communications or when under minimal pressure.
5 = Moderate Severe – Generally has difficulty in organizing thoughts, YMRS 10: Appearance
as evidence by frequent irrelevancies, disconnectedness, or loosening 0 = Appropriate dress and grooming.
of associations when not under pressure. 1 = Minimally unkempt.
6 = Severe – Thinking is seriously derailed and internally inconsistent, 2 = Poorly groomed and moderately disheveled; Overdressed.
resulting in gross irrelevancies and disruption of thought processes, 3 = Disheveled; partly clothed; garish make-up.
which occur almost constantly. 4 = Completely unkempt; decorated; bizarre garb.
7 = Extreme – Thoughts are disrupted to the point where the patient is
incoherent. There is marked loosening of associations, which results in YMRS 11: Insight
total failure of communication, (e.g. “word salad”) or mutism. 0 = Present; admits illness, agrees with need for treatment.
1 = Possibly ill.
B.1. The Young Mania Rating Scale (YMRS) 2 = Admits behavior change, but denies illness.
• Appropriate for: Assessment/severity of mania (most 3 = Admits possible change in behavior, but denies illness.
appropriate for bipolar 1 disorder) 4 = Denies any behavior change.
• Administered by: Trained clinician
• Time to complete: 15-30 minutes B.2. HAMILTON RATING SCALE FOR DEPRESSION (HAM-D)
• an 11-item instrument used to assess the severity of mania in • Administered by: Physician or trained raters
patients with a diagnosis of bipolar disorder. • Time to complete: 30 minutes
• The 11 items are: Elevated Mood, Increased Motor Activity • a 17-21 item observer-rated scale to assess presence and
Energy, Sexual Interest, Sleep, Irritability, Speech (Rate and severity of depressive states where anxiety-related symptoms
Amount), Language - Thought Disorder, Content, Disruptive - are prevalent and no other depressive symptoms
Aggressive Behaviour, Appearance and Insight. • 9 items are scored 0-4, the further 8 are scored 0-2, as these
represent variables which do not lend themselves to
YMRS features operationally-defined anchor points and the quantitative rating (0=absent; 1=doubtful or slight; 2=mild;
normal expected score is >=20. 3=moderate; 4=severe. 0=absent; 1=doubtful or slight;
Ratings are based on patient self-reporting, combined with 2=clearly present). Items 18-21 are not regarded as
clinician observation (accorded greater score). measuring the intensity of depression and are commonly
omitted.
YMRS 1: Elevated Mood • A score of 11 is generally regarded as indicative of a
0 = Absent. diagnosis of depression.
1 = Mildly or possibly increased on questioning. • HAM-D contains items that assess:
2 = Definite subjective elevation: Optimistic, self confident; cheerful; • Somatic symptoms
appropriate to content. • Insomnia
3 = Elevated; inappropriate to content; humorous. • Working capacity and interest
4 = Euphoric; inappropriate laughter; singing. • Mood
• Guilt
YMRS 2: Increased Motor Activity • Psychomotor retardation
0 = Absent. • Agitation
1 = Subjectively increased. • Anxiety
2 = Animated; gestures increased. • Insight
3 = Excessive energy; hyperactive at times; restless (can be calmed).
4 = Motor excitement; continuous (cannot be calmed). Instructions: For each item select the “cue” which best describes the
patient.
YMRS 3: Sexual Interest
0 = Normal; not increased. 1: Depressed Mood (Sadness, hopeless, helpless, worthless)
1 = Mildly or possibly increased. - 0 = Absent
2 = Definite subjective increase on questioning. - 1 = These feelings states indicated only on questioning
3 = Spontaneous sexual content; elaborates on sexual matters; - 2 = These feeling states spontaneously reported verbally
hypersexual by self report. - 3 = Communicates feeling states nonverbally—ie, through
4 = Overt sexual acts (toward patients, staff, or interviewer). facial expression, posture, voice, and tendency to weep
- 4 = Patient reports VIRTUALLY ONLY these feeling states in
YMRS 4: Sleep his spontaneous verbal and nonverbal communication
0 = Normal; not decreased. 2: Feelings of Guilt
1 = Sleeping less than normal amount by up to one hour. - 0 = Absent
2 = Sleeping less than normal amount by more than one hour. - 1 = Self-reproach, feels he has let people down
3 = Reports decreased need for sleep. - 2 = Ideas of guilt or rumination over past errors or sinful deeds
4 = Denies need for sleep. - 3 = Present illness is a punishment. Delusions of guilt
- 4 = Hears accusatory or denunciatory voices and/or
YMRS 5: Irritability experiences threatening visual hallucinations
0 = Absent. 3: Suicide
2 = Subjectively increased. - 0 = Absent
4 = Irritable at times during the interview; recent episodes - 1 = Feels life is not worth living
of anger or annoyance on ward (or usual environment). - 2 = Wishes he were dead or any thoughts of possible death to
6 = Frequently irritable during interview; short, curt throughout. self
8 = Hostile, uncooperative, interview impossible. - 3 = Suicide ideas or gesture
- 4 = Attempts at suicide (any serious attempt rates 4)
YMRS 6: Speech 4: Insomnia early
0 = No increase. - 0 = No difficulty falling asleep
2 = Feels talkative. - 1 = Complains of occasional difficulty falling asleep – ie, more
4 = Increased rate or amount at times, verbose at times. than ¼ hour
6 = Push; consistently increased rate and amount; difficult to interrupt. - 2 = Complains of nightly difficulty falling asleep
8 = Pressured; uninterruptible, continuous speech (during the interview).
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5: Insomnia middle Representing the feeling of loss of appetite compared with when well.
- 0 = No difficulty Rate by desire for food or the need to force oneself to eat.
- 1 = Patient complains of being restless and disturbed during
the night 0 Normal or increased appetite.
- 2 = Waking during the night—any getting out of bed rates 2 1
(except for purpose of voiding) 2 Slightly reduced appetite.
3
B.3. Montgomery-Asberg Depression Rating Scale 4 No appetite. Food is tasteless.
• 10-item scale to measure the core symptoms and cognitive 5
features of clinical depression 6 Needs persuasion to eat at all.
• Originally a subscale of Comprehensive Psychopathological
Rating Scale, or CPRS (Asberg et al. 1978) MADRS 6: Concentration Difficulties
• Symptoms are rated on a scale from 0-6 Rate only difficulty with concentration, regardless of circumstances
• Anchor points at ratings of 0, 2, 4, and 6 If patient reports no need to concentrate (e.g., on vacation, not working),
probe on ability to concentrate on other normal activities (reading paper,
MADRS 1: Apparent Sadness conversations, etc)
Representing despondency, gloom and despair (more than just transient Use the script, ask all questions
low spirits) reflected in speech, facial expressions, and posture. Rate by Representing difficulties in collecting one’s thoughts mounting to
depth and inability to brighten up. incapacitating lack of concentration. Rate according to the intensity,
Rate by observation frequency, and degree of incapacity produced.

0 No sadness 0 No difficulties concentrating.

1 1
2 Looks dispirited 2 Occasional difficulties in collecting one’s
3 thoughts.
4 Appears sad and unhappy most of the time 3
5 4 Difficulties in concentrating and sustaining
6 Looks miserable all the time. Extremely thought which reduces the ability to read or
despondent. hold a conversation.
5
MADRS 2: Reported Sadness 6 Unable to read or converse without great
Representing reports of depressed mood, regardless of whether it is difficulty.
reflected in appearance or not. Rate according to intensity, duration and
the extent to which the mood is reported to be influenced by events. MADRS 7: Lassitude
Rate the ability to start activities or tasks
0 Occasional sadness in keeping with the Determine if tasks/activities were actually started
circumstances. Probe to determine if normal daily living activities were affected
1 • If affected, determine if outside assistance was required (such
2 Sad or low; brightens up without difficulty. as friends or family members)
3 Representing a difficulty getting started or slowness initiating and
4 Pervasive feelings of sadness or performing everyday activities.
gloominess. The mood is still influenced
by external circumstances. 0 Hardly any difficulty getting started. No
5 sluggishness.
6 Continuous or unvarying sadness. 1
2 Difficulties starting activities.
MADRS 3: Inner Tension 3
Representing feelings of ill defined discomfort, edginess, inner turmoil, 4 Difficulties in starting simple routines which
mental tension mounting to either panic, dread, or anguish. Rate are carried out with effort.
according to the intensity, frequency, duration, and the extent of 5
reassurance called for. 6 Complete lassitude. Unable to do anything
without help.
0 Placid. Only fleeting inner tension.
1 MADRS 8: Inability to Feel
2 Some feelings of edginess or ill-defined Probe for subject’s normal level of activities in which he/she participates
discomfort. • Determine the level of disinterest (if appropriate) in
3 participating.
4 Continuous feelings of inner tension or • Ask the subject why the level has changed.
intermittent panic, which can be mastered Determine if subject is able to connect with others, such as family or
with some difficulty. friends
5 Representing the subjective experience of reduced interest in the
6 Unrelenting dread or anguish. surroundings or activities that normally give pleasure. The ability to
Overwhelming react with adequate emotion to circumstances or people is reduced.
panic.
0 Normal interest in surroundings and other
MADRS 4: Reduced Sleep people.
Probe for and rate any sleep related issues, including restless sleep and 1
any trouble falling asleep. 2 Reduced ability to enjoy usual interests.
Distinguish if symptom is normal (e.g., if an infant is in the household, 3
broken sleep could be considered normal) 4 Loss of interest in surroundings. Loss of
Representing the experience of reduced duration or depth of sleep feelings for friends and acquaintances.
compared with the subject’s normal pattern when well. Rate past week. 5
6 The experience of being emotionally
0 Sleeps as usual. paralyzed, inability to feel anger, grief or
1 pleasure and a complete or even painful
2 Slight difficulty dropping off to sleep or failure to feel for close relatives and friends
slightly reduced, light or fitful sleep.
3 MADRS 9: Pessimistic Thoughts
4 Sleep reduced or broken by at least 2 Determine the occurrence and severity of pessimistic thoughts/lack of
hours. optimism
5 Determine if subject feels as if they have let others down or have done
6 Less than 2 or 3 hours of sleep. something wrong
• Determine if feelings are justified/rational
MADRS 5: Reduced Appetite • Probe for subjective awareness of guilt
Frequently underrated item: This item measures both appetite and Representing thoughts of guilt, inferiority, self-reproach, sinfulness,
interest in eating. Raters must ask about both symptoms remorse, and ruin.
Do not assume a change in weight reflects an increase/decrease in
appetite or interest in eating 0 No pessimistic thoughts.
Use all scripted probing questions, even if patient reports appetite is 1
normal 2 Fluctuating ideas of failure, self-reproach
or self-deprecation.
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4 Persistent self-accusations, or definite but
still rational ideas of guilt or sin,
increasingly pessimistic about the future.
5
6 Delusions of ruin, remorse, or
unredeemable sin.
Self–accusations which are absurd or
unshakable.

MADRS 10: Suicidal Thoughts

It is important to evaluate the frequency or severity of suicidal thoughts
Determine if the subject has made any plans for suicide
For safety, subjects that have current plans for suicide should be treated
appropriately
Representing the feeling that life is not worth living, that a natural death
would be welcome, suicidal thoughts, and preparation for suicide.
Suicidal attempts should not, in themselves, influence the rating.

0 Enjoys life or takes it as it comes.

1
2 Weary of life. Only fleeting suicidal
thoughts.
3
4 Probably better off dead. Suicidal
thoughts are common and suicide is
considered as a possible solution, but
without specific plans or intention.
5
6 Explicit plans for suicide when there is an
opportunity.
Active preparations for suicide.

Disease Severity MADRS

• No Symptoms 0 – 12
• Mild 13 – 21
• Moderate 22 – 29
• Severe 30 – 60

C.1. HAMILTON ANXIETY RATING SCALE (HAM-A)

Instructions: This checklist is to assist the physician or psychiatrist in
evaluating each patient as to his degree of anxiety and patholigical
condition. Please fill in the appropriate rating:
NONE = 0
MILD = 1
MODERATE = 2
SEVERE = 3
SEVERE, GROSSLY DISABLING = 4

ITEM RATING

Anxious Worries, anticipation of the worst, fearful

anticipation, irritability
Tension Feelings of tension, fatigability, startle
response, moved to tears easily , trembling, feelings of
restlessness, inability to relax
Fears Of dark, of strangers, of being left alone, of
animals, of traffic, of crowds
Insomnia Difficulty in falling asleep, broken sleep,
unsatisfying sleep and fatigue on waking, dreams,
nightmares, night-terrors
Intellectual (cognitive) Difficulty in concentration,
poor memory
Depressed Mood Loss of interest, lack of pleasure in
hobbies, depression, early waking, diurnal swing
Somatic (muscular) Pains and aches, twitching,
stiffness, myoclonic jerks, grinding of teeth, unsteady
voice, increased muscular tone
Somatic (sensory) Tinnitus, blurring of vision, hot
and cold flushes, feelings of weakness, picking
sensation
Cardiovascular Symptoms Tachycardia,
palpitations, pain in chest, throbbing of vessels, fainting
feelings, missing beat
Respiratory Symptoms Pressure or constriction in
chest, choking feelings, sighing, dyspnea
Gastrointestinal Symptoms Difficulty in swallowing,
wind, abdominal pain, burning sensations, abdominal
fullness, nausea, vomiting, borborygmi, looseness of
bowels, loss of weight, constipation
Genitourinary Symptoms Frequency of micturition,
urgency of micturition, amenorrhea, menorrhagia,
development of frigidity, premature ejaculation, loss of
libido, impotence
Autonomic Symptoms Dry mouth, flushing, pallor,
tendency to sweat, giddiness, tension headache, raising
of hair
Behavior at Interview Fidgeting, restlessness or
acing, tremor of hands, furrowed brow, strained face,
sighing or rapid respiration, facial pallor, swallowing,
belching, brisk tendon jerks, dilated pupils,
exophthalmos
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