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