BUSH AND FRANCIS CATATONIA SCALE

1. EXCITEMENT:

Extreme hyperactivity, constant movement, without rest or without apparent purpose. It should not
be attributed to akathisia or agitation for a definite purpose.
0 = Absent.
1 = Excessive but intermittent movement.
2 = Constant hyperkinetic movement, without rest periods.
3 = Catatonic excitement, frenetic and endless motor activity.

2. IMMOBILITY / STUPOR:

The patient is mutist, immobile, or extremely hypoactive. Does not respond to the stimulus (even if it
is painful) or presents only a minimal response.
0 = Absent
1 = Sitting abnormally still, may interact briefly.
2 = Virtually no interaction with the external world.
3 = Stuporous, does not react to painful stimuli.

3. MUTISM:

State of absence of verbal response, not always associated with immobility. There is no verbal
response or it is minimal.
0 = Absent
1 = Does not respond verbally to most questions, incomprehensible whisper
2 = Speaks less than 20 words in a period of 5 minutes.
3 = Does not speak.

4. STARE:

There is no or minimal visual recognition of the medium, decreased flickering.

0 = Absent
1 = Poor eye contact, repeated periods of less than 20 seconds in attention, decreased
blinking
2 = Periods of gaze fixation for more than 20 seconds, changes attention, only looks
occasionally.
3 = Fixed gaze, non-reactive.

5. POSTURE / CATALEPSY

Spontaneously maintain body posture, even the usual ones such as standing or sitting for long
periods without reacting. It also includes facial posture, grimaces, exaggerated pursing of the lips or
others such as the psychological pillow where the patient, when lying in bed, keeps his head
elevated as if he had a cushion.

Or, when sitting, it adopts strange positions with the upper and lower portions of the body contorted.
He holds his arms above his head, or raises them as if he were praying, or adopts strange positions
of his fingers and hands.
0 = Absent.
1 = Less than a minute.
2 = Between 1 minute and 15 minutes.
3 = Strange or habitual posture maintained for more than 15 minutes.

6. GESTICULATIONS:

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Maintain a strange facial expression.

0 = Absent.
1 = Less than 10 seconds.
2 = Less than 1 minute.
3 = Strange expression or maintained for more than 1 minute.

7. ECOPHENOMENA:

Echopraxia / Echolalia.
Mimic the examiner's speech or movements. The patient spontaneously copies the examiner's
movements. The patient constantly repeats the examiner's verbal expressions.
0 = Absent.
1 = Occasional.
2 = Frequent.
3 = Constant

8. STEREOTYPE:

Repetitive and purposeless motor activity, usually surprising. The abnormality is not given by the
motor act itself but by its frequency. (Ex. Finger movements, repeated touching, patting or rubbing).
0 = Absent.
1 = Occasional.
2 = Frequent.
3 = Constant.

9. MANNERISMS:

Strange propositional movements. (Ex. Jumping instead of walking, walking on tiptoe, persevering
handshake or exaggerated caricatures of habitual movements) The abnormality is inherent to the
act.

0 = Absent.
1 = Occasional.
2 = Frequent.
3 = Constant.

10. VERBIGERATION:

Verbal stereotypy. Repetition of phrases or sentences like a “broken record”.

0 = Absent.
1 = Occasional.
2 = Frequent, difficult to interrupt.
3 = Constant.

11. RIGIDITY:

Maintain a rigid position despite efforts to mobilize it. Exclude the gear wheel and the tremor if
present.
0 = Absent.
1 = Mild resistance.
2 = Moderate.
3 = Severe, cannot be changed position.

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 12. NEGATIVISM:

Seemingly unmotivated resistance to instructions or efforts to move or examine the patient.

Contrary behavior, it does exactly the opposite of the given instruction.
0 = Absent.
1 = Mild resistance and/or occasionally against.
2 = Moderate resistance and/or frequently against.
3 = Serious resistance and/or continually against.

13. WAXY FLEXIBILITY:

When trying to reposition the patient, it offers initial resistance and then allows repositioning. It is
similar to bending a sail.
0 = Absent.
3 = Present.

14. RETREAT:

Refusal to eat, drink and/or make eye contact.

0 = Absent.
1 = Minimal oral intake / Rejection of interaction of less than one day.
2 = Minimal oral intake / Refusal to interact for one day.
3 = No oral intake / Refusal to interact for a day or more.

15. IMPULSIVENESS:

The patient suddenly adopts inappropriate behaviors (eg. Runs down hallways, screams, or takes
off clothes) without provocation. He subsequently gives a superficial explanation for his actions or
no explanation at all.

0 = Absent.
1 = Occasional.
2 = Frequent.
3 = Constant or without the possibility of modifying.

16. AUTOMATIC OBEDIENCE:

He cooperates excessively with the examiner's requests or spontaneously persists in the movement
that he was asked to perform.
Despite the instruction to the contrary, the patient allows the examiner, with slight pressure, to move
his limbs into a new position (posture) which is then maintained by the patient despite the
instructions to the contrary.

0 = Absent.
1 = Occasional.
2 = Frequent.
3 = Constant.

17. MITGEHEN:

“Flexible lamp” The patient's arm rises in response to slight pressure on one of his fingers, despite
instructions to the contrary.

0 = Absent.
3 = Present.

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 18. GEGENHALTEN:

Resistance to passive movement, proportional to the strength of the stimulus, appears to be

automatic without the patient's intention.
The patient resists being manipulated by the examiner and his counterforce is matched to that
applied by the examiner.

0 = Absent.
3 = Present.

19. ENVIRONMENT

The patient appears to be “stuck” in his movements, he appears indecisive or hesitant, which
results in contradictory behavior between his non-verbal and verbal behavior. It is explored by
offering your hand to shake it in greeting, while telling the patient: “don't shake my hand, I don't
want you to shake it.”

0 = Absent.
3 = Present.

20. GRIP REFLEX:

From the neurological examination.

0 = Absent.
3 = Present.

21. PERSEVERANCE:

The patient repeatedly returns to the same topic or persists in a movement.

0 = Absent.
3 = Present.

22. FIGHT:

Generally without a defined purpose, afterwards it does not give any explanation or makes a
superficial justification.

0 = Absent.
1 = Triggered occasionally, with low harmful potential.
2 = Triggered frequently, with moderate harmful potential.
3 = Serious danger to others.

23. AUTONOMIC ABNORMALITY:

Please indicate: Temperature, blood pressure, pulse, respiratory rate, diaphoresis.

0 = Absent.
1 = Abnormality in a parameter (Exclude previous arterial hypertension).
2 = Abnormality in two parameters.
3 = Abnormality in three or more parameters.

b. Standardized procedure to carry out the clinical interview in the patient in whom catatonia is
suspected.

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Observe the patient as he attempts to engage in conversation.
During the Interview:
 The examiner must scratch his head exaggeratedly.
 Examine the patient's arm for “cogwheel.” Try to reposition the arm, instructing the patient:
“keep your arm very loose” then alternately flex the arm with little force and with greater
force.
 Ask the patient to extend his arm. Place one finger under your palm and try to raise it slowly
after saying, “Don't let me lift your arm.”
 Extend your hand to him in greeting while saying, “Don't shake my hand.”

 Reaching into your pocket, tell the patient: “Show me your tongue, I want to insert a needle
into your tongue.”

 Look for the grasp reflex.

Review the nursing chart and notes from the last 24 hours. Oral intake, vital signs and any
incidents.
Try to observe the patient indirectly, at least for a short period each day.

a) Activity level.
b) Abnormal movements.
c) Echopraxia.
d) Rigidity.
e) Negativism.
f) Waxy flexibility.
g) Gegenhalten.
h) Mitgehen.
i) Ambitendency.
j) Automatic obedience.
k) Grip reflex.