Intro Merged

Sana Al Sehar
Zoha Shahid
Nayyab Taqqadus
Assessment Scales
Clinical Psychology Internship and Report Writing
Ma’am Nabeela Raza
Riphah International University (GGC)

Islamabad
Bipolar Depression Rating Scale (BDRS)
_____________________________________________________________________________________________
INSTRUCTIONS: “I am going to ask you some questions about symptoms you may have. When
answering please keep in mind that we are focusing only on how you are now, or have been over the
last few days.”
√) one answer for each of the questions below.

Check or tick (√
1. DEPRESSED MOOD
Self reported and/or observed depression as evidenced by gloom, sadness, pessimism, hopelessness, and
helplessness
0 Nil
1 Mild [brief or transient periods of depression, or mildly depressed mood]
2 Moderate [depressed mood is clearly but not consistently present and other emotions are
expressed, or depression is of moderate intensity]
3 Severe [pervasive or continuous depressed mood of marked intensity]
2. SLEEP DISTURBANCE: score either A or B

Change in total amount of sleep over a 24-hour cycle, rated independent of the effect of external factors
A: Insomnia (reduction in total sleep time)
0 Nil
1 Mild [up to 2 hours]
2 Moderate [2 – 4 hours]
3 Severe [more than 4 hours]
OR
B: Hypersomnia (increase in total sleep time, inclusive of daytime sleep)
0 Nil
1 Mild [less than 2 hours, or normal amount but non-restorative]
2 Moderate [greater than 2 hours]
3 Severe [greater than 4 hours]
3. APPETITE DISTURBANCE: score either A or B

Change in appetite and food consumption, rated independent of the effect of external factors
A. Loss of appetite
0 Nil
1 Mild [no change in food intake, but has to push self to eat or reports that food has lost taste]
2 Moderate [some decrease in food intake]
3 Severe [marked decrease in food intake, hardly eating]
OR
B. Increase in appetite
0 Nil
1 Mild [no change in food intake, but increased hunger]
2 Moderate [some increase in food intake, e.g., comfort eating]
3 Severe [marked increase in food intake or cravings]
_____________________________________________________________________________________________
4. REDUCED SOCIAL ENGAGEMENT
Reports reduced social and interpersonal engagement or interactions
0 Nil [normal]
1 Mild [slight reduction in social engagement with no impairment in social or interpersonal
function]
2 Moderate [clear reduction in social engagement with some functional sequelae, e.g., avoids
some social engagements or conversations]
3 Severe [marked reduction in social interaction or avoidance of almost all forms of social
contact, e.g., refuses to answer the phone or see friends or family]
5. REDUCED ENERGY AND ACTIVITY

Reduced energy, drive and goal directed behaviour
0 Nil
1 Mild [able to engage in usual activities but with increased effort]
2 Moderate [significant reduction in energy leading to reduction of some role-specific activities]
3 Severe [leaden paralysis or cessation of almost all role specific activities, e.g., spends
excessive time in bed, avoids answering the phone, poor personal hygiene]
6. REDUCED MOTIVATION
Reports of subjective reduction in drive, motivation, and consequent goal directed activity
0 Nil [normal motivation]

1 Mild [slight reduction in motivation with no reduction in function]
2 Moderate [reduced motivation or drive with significantly reduced volitional activity or requires
substantial effort to maintain usual level of function]
3 Severe [reduced motivation or drive such that goal directed behaviour or function is markedly
reduced]
7. IMPAIRED CONCENTRATION AND MEMORY

Subjective reports of reduced attention, concentration, or memory, and consequent functional impairment
0 Nil
1 Mild [slight impairment of attention, concentration, or memory with no functional impairment]
2 Moderate [significant impairment of attention, concentration, or forgetfulness with some
functional impairment]
3 Severe [marked impairment of concentration or memory with substantial functional impairment,
e.g., unable to read or watch TV]
8. ANXIETY
Subjective reports of worry, tension, and/or somatic anxiety symptoms e.g., tremor, palpitations, dizziness,
light-headedness, pins and needles, sweating, dyspnoea, butterflies in the stomach, or diarrhoea
0 Nil
1 Mild [transient worry or tension about minor matters]
2 Moderate [significant anxiety, tension, or worry, or some accompanying somatic features]
3 Severe [marked continuous anxiety, tension, or worry that interferes with normal activity; or
panic attacks]
9. ANHEDONIA
Subjectively reduced ability to experience pleasure in usual activities
0 Nil
1 Mild [slight reduction in pleasure from usually pleasurable activities]
2 Moderate [significant reduction in pleasure from usually pleasurable activities; some pleasure
from isolated activities retained]
3 Severe [complete inability to experience pleasure]
_____________________________________________________________________________________________
10. AFFECTIVE FLATTENING
Subjective sense of reduced intensity or range of feelings or emotions
0 Nil
1 Mild [slight constriction of range of affect, or transient reduction in range or intensity of feelings]
2 Moderate [significant constriction of range or intensity of feelings with preservation of some
emotions, e.g., unable to cry]
3 Severe [marked and pervasive constriction of range of affect or inability to experience usual
emotions]
11. WORTHLESSNESS
Subjective sense, or thoughts, of decreased self-value or self-worth
0 Nil
1 Mild [slight decrease in sense of self-worth]
2 Moderate [some thoughts of worthlessness and decreased self-worth]
3 Severe [marked, pervasive, or persistent feelings of worthlessness, e.g., feels others better off
without them, unable to appreciate positive attributes]
12. HELPLESSNESS AND HOPELESSNESS

Subjective sense of pessimism or gloom regarding the future, inability to cope, or sense of loss of control
0 Nil
1 Mild [occasional and mild feelings of not being able to cope as usual; or pessimism]
2 Moderate [often feels unable to cope, or significant feelings of helplessness or hopelessness
which lift at times]
3 Severe [marked and persistent feelings of pessimism, helplessness, or hopelessness]
13. SUICIDAL IDEATION

Thoughts or feelings that life is not worthwhile; thoughts of death or suicide
0 Nil
1 Mild [thoughts that life is not worthwhile or is meaningless]
2 Moderate [thoughts of dying or death, but with no active suicide thoughts or plans]
3 Severe [thoughts or plans of suicide]
14. GUILT
Subjective sense of self blame, failure, or remorse for real or imagined past errors
0 Nil
1 Mild [slight decrease in self-esteem or increased self-criticism]
2 Moderate [significant thoughts of failure, self-criticism, inability to cope, or ruminations
regarding past failures and the effect on others; able to recognise as excessive]
3 Severe [marked, pervasive, or persistent guilt, e.g., feelings of deserving punishment; or does
not clearly recognise as excessive]
15. PSYCHOTIC SYMPTOMS

Presence of overvalued ideas, delusions, or hallucinations
0 Nil [absent]
1 Mild [mild overvalued ideas, e.g., self-criticism or pessimism without clear effect on behaviour]
2 Moderate [significant overvalued ideas with clear effect on behaviour, e.g., strong guilt feelings,
clear thoughts that others would be better off without them]
3 Severe [clear psychotic symptoms, e.g., delusions or hallucinations]
_____________________________________________________________________________________________
16. IRRITABILITY
Reports uncharacteristic subjective irritability, short fuse, easily angered, manifested by verbal or physical
outbursts
0 Nil
1 Mild [slight subjective irritability; may not be overtly present]
2 Moderate [verbal snappiness and irritability that is clearly observable in interview]
3 Severe [reports of physical outbursts, e.g., throwing/breaking objects, or markedly abusive
verbal outbursts]
17. LABILITY
Observed mood lability or reported mood swings
0 Nil
1 Mild [subjective reports of mild increase in mood lability]
2 Moderate [mood lability clearly observable, moderate in intensity]
3 Severe [marked and dominant mood lability, frequent or dramatic swings in mood]
18. INCREASED MOTOR DRIVE

Subjective reports and objective evidence of increased motor drive and motor activity
0 Nil [normal motor drive]

1 Mild [slight increase in drive, not observable in interview]
2 Moderate [clear and observable increase in energy and drive]
3 Severe [marked or continuous increase in drive]
19. INCREASED SPEECH

Observed increase in either the rate or quantity of speech, or observed flight of ideas
0 Nil
1 Mild [slight increase in the rate or quantity of speech]
2 Moderate [racing thoughts, significantly more talkative, clearly distractible, or some
circumstantiality; does not impede interview]
3 Severe [flight of ideas; interferes with interview]
20. AGITATION
Observed restlessness or agitation
0 Nil [normal]
1 Mild [slight restlessness]
2 Moderate [clear increase in level of agitation]
3 Severe [marked agitation, e.g., near continuous pacing or wringing hands]
TOTAL
BIPOLAR DISORDER SELF-ASSESSMENT TEST
(Clinician version)
Introduction
This self-completed measure provides a first-stage screen for the possibility of Bipolar Disor-
der by assessing features of ‘highs’. It was initially made available in October 2001 and was
further refined in May 2005 on the basis of several Institute research studies and feedback
from the community.
Author
Professor Gordon Parker.
Scoring instructions
Items are scored as follows:
Much more than usual = 2
Somewhat more than usual = 1
No more than usual = 0
The total score is the sum of all 27 items.
Results
22 or more
A score of 22 or more, together with episodes of clinical depression, suggest possible
Bipolar I or II Disorder, and would warrant detailed clinical assessment.
Less than 22
A score of less than 22 is only returned by about 2% of those with true Bipolar Disorder, so
that if the score is less than 22, the likelihood of the individual having the condition is low –
but cannot be excluded.
This self-assessment test may also be done online, on the Black Dog Institute
website – at: www.blackdoginstitute.org.au
This document may be freely downloaded and distributed on condition no change is made to the content. The information in this
document is not intended as a substitute for professional medical advice, diagnosis or treatment. Not to be used for commercial purposes
and not to be hosted electronically outside of the Black Dog Institute website. www.blackdoginstitute.org.au
BIPOLAR DISORDER SELF-ASSESSMENT TEST
This Self-Assessment Test comprises three initial questions followed by a checklist. Only if you
answer ‘yes’ to the first three questions should you continue on with the checklist.
At the end of the test you will be given your results.
Firstly, have you had episodes of clinical depression – involving a period of at least 2 weeks
where you were significantly depressed and unable to work or only able to work with difficulty –
and had at least 4 of the following:
• Loss of interest and pleasure in most things
• Appetite or weight change
• Sleep disturbance
• Physical slowing or agitation
• Fatigue or low energy
• Feeling hopeless and helpless
• Poor concentration
• Suicidal thoughts?
If YES, proceed.
Secondly, do you have times when your mood ‘cycles’, that is, do you experience ‘ups’ as well as
depressive episodes?
If YES, proceed.
Thirdly, during the ‘ups’ do you feel more ‘wired’ and ‘hyper’ than you would experience during
times of normal happiness?
If YES, proceed.
Please complete the checklist below, rating the extent to which each item applies to you during
such ‘up’ times.
This document may be freely downloaded and distributed on condition no change is made to the content. The information in this document is
not intended as a substitute for professional medical advice, diagnosis or treatment. Not to be used for commercial purposes and not to be
hosted electronically outside of the Black Dog Institute website. www.blackdoginstitute.org.au
Somewhat
No more Much more
more than
than usual than usual
usual
1. Feel more confident and capable
2. See things in a new and exciting light
3. Feel very creative with lots of ideas and plans
4. Become over-involved in new plans and projects
5. Become totally confident that everything you do will succeed
6. Feel that things are very vivid and crystal clear
7. Spend, or wish to spend, significant amounts of money
8. Find that your thoughts race
9. Notice lots of coincidences occurring

10. Note that your senses are heightened and your emotions
intensified
11. Work harder, being much more motivated
12. Feel one with the world and nature
13. Believe that things possess a ‘special meaning’
14. Say quite outrageous things
15. Feel ‘high as a kite’, elated, ecstatic and ‘the best ever’
16. Feel irritated
17. Feel quite carefree, not worried about anything

18. Have much increased interest in sex (whether thoughts and/or
actions)
19. Feel very impatient with people
20. Laugh more and find lots of things humorous
21. Read special significance into things
22. Talk over people
23. Have quite mystical experiences
24. Do fairly outrageous things
25. Sleep less and not feel tired
26. Sing
27. Feel angry
Your doctor will help you score and understand this test when you are finished.
This document may be freely downloaded and distributed on condition no change is made to the content. The information in this document is not intended as a substitute for
professional medical advice, diagnosis or treatment. Not to be used for commercial purposes and not to be hosted electronically outside of the Black Dog Institute website.
www.blackdoginstitute.org.au
BSDS
Instructions:
1. Please read through the entire passage below before filling in any blanks.
Some individuals notice that their mood and/or energy levels shift drastically from time to
time___. These individuals notice that, at times, their mood and/or energy level is very low, and
at other times, very high___. During their ‘‘low’’ phases, these individuals often feel a lack of
energy; a need to stay in bed or get extra sleep; and little or no motivation to do things they need
to do___. They often put on weight during these periods___. During their low phases, these
individuals often feel ‘‘blue’’, sad all the time, or depressed___. Sometimes, during these low
phases, they feel hopeless or even suicidal___. Their ability to function at work or socially is
impaired___. Typically, these low phases last for a few weeks, but sometimes they last only a
few days___. Individuals with this type of pattern may experience a period of ‘‘normal’’ mood in
between mood swings, during which their mood and energy level feels ‘‘right’’ and their ability
to function is not disturbed___. They may then notice a marked shift or ‘‘switch’’ in the way
they feel___. Their energy increases above what is normal for them, and they often get many
things done they would not ordinarily be able to do___. Sometimes, during these ‘‘high’’
periods, these individuals feel as if they have too much energy or feel ‘‘hyper’’___. Some
individuals, during these high periods, may feel irritable, ‘‘on edge’’, or aggressive___. Some
individuals, during these high periods, take on too many activities at once___. During these high
periods, some individuals may spend money in ways that cause them trouble___. They may be
more talkative, outgoing, or sexual during these periods___. Sometimes, their behavior during
these high periods seems strange or annoying to others___. Sometimes, these individuals get into
difficulty with co-workers or the police, during these high periods___. Sometimes, they increase
their alcohol or non-prescription drug use during these high periods___.
2. Now that you have read this passage, please check one of the following four boxes:
( ) This story fits me very well, or almost perfectly

( ) This story fits me fairly well
( ) This story fits me to some degree, but not in most respects
( ) This story does not really describe me at all
3. Now please go back and put a check after each sentence that definitely describes you.
The Bipolar Spectrum Diagnostic Scale
BSDS Scoring:
Each sentence checked is worth one point. Add six points for ‘‘fits me very well,’’ 4 points for
‘‘fits me fairly well,’’ and two points for ‘‘fits me to some degree.’’
Total score Likelihood of bipolar disorder (from Ghaemi)

0 – 6 Highly unlikely
7 – 12 Low risk
13– 19 Moderate risk
20– 25 High risk
Optimum threshold for positive diagnosis: score of 13 or above.
Sensitivity to Bipolar I & II: .75

Specificity in unipolar depressed outpatients: .93
Diagnostic Likelihood for Positive (DLR+): 10.7

Diagnostic Likelihood for Positive (DLR+): .27
Reference:
Ghaemi, S. N., Miller, C. J., Berv, D. A., Klugman, J., Rosenquist, K. J., & Pies, R. W. (2005).
Sensitivity and specificity of a new bipolar spectrum diagnostic scale. Journal of
Affective Disorders, 84(2-3), 273-277.
STABLE RESOURCE TOOLKIT
CIDI-based Screening Scale for Bipolar Spectrum Disorders -

Overview
Version 3.0 of the World Health Organization (WHO) Composite International Diagnostic
Interview (CIDI) was validated as being capable of generating conservative diagnoses of both
threshold and sub-threshold bipolar disorder. The CIDI Version 3.0 is a fully structured lay-
administered diagnostic interview. DSM-IV criteria are used to define mania, hypomania, and
major depressive episode. The referenced article states that for the purposes of the paper, bipolar
spectrum was defined as a lifetime history of BP-I, BP-II or sub-threshold bipolar disorder. The
results reported suggest that the prevalence of DSM-IV bipolar spectrum disorder is at least 4.0%1.
In this published study, CIDI–based Bipolar Disorder screening scales were also evaluated.
Evaluation of the sensitivity and positive predictive value showed that the CIDI screening scales
met the desired requirement of detecting a high proportion of true cases while minimizing the
number of false positives.
Clinical Utility
This is a clinician administered screening tool:
n T he CIDI-based screening scale is capable of identifying both threshold and sub-threshold
bipolar disorder with good accuracy.
n The scale detected between 67-96% of true cases.
n T his compares very favorably with the widely-used MDQ screening scale for bipolar disorder,
which was found in one study to detect only 28% of true cases in a general population
sample, although higher sensitivity (58-73) has been reported in 3 studies using the MDQ in
out-patient populations with depression.
Scoring
Scoring information is provided on the following two pages.
Psychometric Properties
n T he positive predictive value (PPV) indicates that the proportion of true cases among the
screened positives varies across populations as a function of prevalence. PPV may be high in
general medical samples and considerably higher in specialty mental health outpatient samples.
n E stimates of PPV have been generated for a number of important sub-populations (e.g.
primary care users weighted by number of visits in the past year; low-income residents of
urban areas, etc.) and are posted on the NCS web site (www.hcp.med.harvard.edu/ncs/
bpdscreen); PPV for 3 populations are provided, for reference, on the second page of the
Scoring document.
1. Kessler RC, et al; Validity of the assessment of bipolar disorder in the WHO composite international diagnostic
interview; Journal of Affective Disorders 96 (2006) 259-269
CIDI 3.0 Bipolar Screening Scales Scoring

The complete set of 12 Questions takes approximately three minutes to complete.
The Scale has 12 Questions

Note: To “endorse” = Answer “yes”, in a yes-no response
2 Stem Questions: Question 1 & 2

Respondents who fail to endorse either of these first two questions are skipped out of the
remainder of the question series.
1 Criterion B Screening Question: Question 3

n R
espondents who fail to endorse this question after endorsing one of the first two stem
questions (above) are skipped out of the remainder of the question series.
n R
espondents who do endorse this question are then administered the 9 additional
symptom questions.
Note: In a general population sample, it can be expected that as many as 90% of the sample will skip out by the
end of this third question.
9 Criterion B Symptom Questions

n E
ach of the 9 symptom questions are administered

Note: the first question in this group is asked only if the first Stem Question (above) is endorsed, if this scenario
occurs, then only the 8 remaining symptom questions would be administered.
n B
ased on positive endorsement of the 9 (or 8) questions in this category, the proportion
of screened positives that are true cases are indicated in the tables on the following page.
Again, positive predictive values vary across populations as a function of prevalence.
However, the author has indicated that scores may be collapsed for reference
purposes, if desired, as follows:
• Very high risk (80% or more) 9 questions with positive endorsement
• High risk (50-79%) 7-8 questions with positive endorsement
• Moderate risk (25-49%) 6 questions with positive endorsement
• Low risk (5-24%) 5 questions with positive endorsement
• Very low risk (less than 5%) 0-4 questions with positive endorsement
Diagnoses based on the screening scales have excellent concordance with diagnoses based on the full
WHO Composite International Diagnostic Interview (CIDI 3.0). CIDI Diagnoses, in turn, have excellent
concordance with clinical diagnoses based on blinded SCID clinical appraisal interviews.
CIDI 3.0 Bipolar Screening Scales Scoring

The complete set of 12 Questions takes approximately three minutes to complete.
Positive Predictive Values in sub-populations for CIDI-based Screening Scales
Number of For respondents For respondents For respondents

Questions who have seen who have seen who have received
Endorsed a primary care a primary care specialty mental
physician at least physician at least health treatment in
12 times in the year once in the year the year before the
before the interview before the interview interview.
0 Questions = Y PPV = 0.0 PPV = 0.2 PPV = 0.0

1 Question = Y PPV = 0.0 PPV = 0.2 PPV = 0.0
AUC = .865 AUC = .854 AUC = .800
PPV = Positive Predictive Value: The proportion of screened positives that are true cases (of bipolar disorder for
this scale)
AUC = Area Under the Receiver Operating Characteristic Curve; the area measures discrimination, that is, the
ability of the test to correctly classify those with and without the condition. [0.90-1 = Excellent; 0.80-0.90 =
Good; 0.70-0.80 = Fair; 0.60-0.70 = Poor]
Diagnoses based on the screening scales have excellent concordance with diagnoses based on the full
WHO Composite International Diagnostic Interview (CIDI 3.0). CIDI Diagnoses, in turn, have excellent
concordance with clinical diagnoses based on blinded SCID clinical appraisal interviews.
CIDI-based Bipolar Disorder Screening Scale
Stem Questions
Euphoria Stem Question
1. Some people have periods lasting several days when they feel much more excited and
full of energy than usual. Their minds go too fast. They talk a lot. They are very restless
or unable to sit still and they sometimes do things that are unusual for them, such as
driving too fast or spending too much money.
Have you ever had a period like this lasting several days or longer?

If this question is endorsed, the next question (the irritability stem question) is skipped and the
respondent goes directly to the Criterion B screening question
Irritability Stem Question
2. Have you ever had a period lasting several days or longer when most of the time you were
so irritable or grouchy that you either started arguments, shouted at people or hit people?
Criterion B Screening Question

3. People who have episodes like this often have changes in their thinking and behavior at the
same time, like being more talkative, needing very little sleep, being very restless, going on
buying sprees, and behaving in many ways they would normally think inappropriate.
Did you ever have any of these changes during your episodes of being excited and full of
energy or very irritable or grouchy?
Criterion B Symptom Questions

Think of an episode when you had the largest number of changes like these at the same
time. During that episode, which of the following changes did you experience?
1. Were you so irritable that you either started arguments, shouted at people, or hit people?
This first symptom question is asked only if the euphoria stem question (#1 above) is endorsed
2. Did you become so restless or fidgety that you paced up and down or couldn’t stand still?
3. Did you do anything else that wasn’t usual for you—like talking about things you would
normally keep private, or acting in ways that you would usually find embarrassing?
4. Did you try to do things that were impossible to do, like taking on large amounts of work?
5. Did you constantly keep changing your plans or activities?
6. Did you find it hard to keep your mind on what you were doing?
7. Did your thoughts seem to jump from one thing to another or race through your head so
fast you couldn’t keep track of them?
8. Did you sleep far less than usual and still not get tired or sleepy?
9. Did you spend so much more money than usual that it caused you to have financial
trouble?
Permission for use Ronald C Kessler, PhD

Evanston Northwestern Healthcare Genome-Wide Association Study of Schizophrenia Pablo V. Gejman, M.D.
VERSION 2.0/MGS
OCT 99 U. SCALE FOR THE ASSESSMENT OF NEGATIVE SYMPTOMS (SANS)
80
______________________________________________________________________________
See SANS Manual for detailed coding definitions (N. Andreason, 1984).
INTERVIEWER: Ratings are to be based on the last 30 days.
NONE SEVERE UNK
AFFECTIVE FLATTENING OR BLUNTING
1. Unchanging Facial Expression 0 1 2 3 4 5 U

The patient's face appears wooden--changes
less than expected as emotional content of
discourse changes.
2. Decreased Spontaneous Movements 0 1 2 3 4 5 U
The patient shows few or no spontaneous
movements, does not shift position, move
extremities, etc.
3. Paucity of Expressive Gestures 0 1 2 3 4 5 U
The patient does not use hand gestures
or body position as an aid in expressing
his ideas.
4. Poor Eye Contact 0 1 2 3 4 5 U
The patient avoids eye contact or "stares
through" interviewer even when speaking.
5. Affective Nonresponsivity 0 1 2 3 4 5 U
The patient fails to laugh or smile when
prompted.
6. Inappropriate Affect 0 1 2 3 4 5 U
The patient's affect is inappropriate or
incongruous, not simply flat or blunted.
7. Lack of Vocal Inflections 0 1 2 3 4 5 U
The patient fails to show normal vocal
emphasis patterns, is often monotonic.
8. Global Rating of Affective Flattening 0 1 2 3 4 5 U
This rating should focus on overall
severity of symptoms, especially
unresponsiveness, inappropriateness and an
overall decrease in emotional intensity.
ALOGIA
9. Poverty of Speech 0 1 2 3 4 5 U
The patient's replies to questions are
restricted in amount, tend to be brief,
concrete, unelaborated.
10. Poverty of Content of Speech 0 1 2 3 4 5 U
The patient's replies are adequate in
amount but tend to be vague, over
concrete or over generalized, and convey
little in information.
SANS CODES
0 = None/Not at All 3 = Moderate U = Unknown/
1 = Questionable 4 = Marked Cannot Be Assessed/
2 = Mild 5 = Severe Not Assessed
VERSION 2.0/MGS
OCT 99 U. SANS (Cont'd)
81
______________________________________________________________________________
NONE SEVERE UNK
11. Blocking 0 1 2 3 4 5 U
The patient indicates, either
spontaneously or with prompting, that his
train of thought was interrupted.
12. Increased Latency of Response 0 1 2 3 4 5 U

The patient takes a long time to reply to
questions, prompting indicates the patient
is aware of the question.
13. Global Rating of Alogia 0 1 2 3 4 5 U

The core features of alogia are poverty of
speech and poverty of content.
AVOLITION/APATHY
14. Grooming and Hygiene 0 1 2 3 4 5 U

The patient's clothes may be sloppy or
soiled, and he may have greasy hair,
body odor, etc.
15. Inpersistence at Work or School 0 1 2 3 4 5 U

The patient has difficulty seeking or
maintaining employment, completing school
work, keeping house, etc. If an inpatient,
cannot persist at ward activities, such as
OT, playing cards, etc.
16. Physical Anergia 0 1 2 3 4 5 U

The patient tends to be physically inert.
He may sit for hours and not initiate
spontaneous activity.
17. Global Rating of Avolition/Apathy 0 1 2 3 4 5 U

Strong weight may be given to one or two
prominent symptoms if particularly
striking.
ANHEDONIA/ASOCIALITY
18. Recreational Interests and Activities 0 1 2 3 4 5 U

The patient may have few or no interests.
Both the quality and quantity of
interests should be taken into account.
SANS CODES
VERSION 2.0/MGS
OCT 99 U. SANS (Cont'd)
82
______________________________________________________________________________
NONE SEVERE UNK
19. Sexual Activity 0 1 2 3 4 5 U

The patient may show decrease in sexual
interest and activity, or no enjoyment
when active.
20. Ability to Feel Intimacy and Closeness 0 1 2 3 4 5 U

The patient may display an inability to
form close or intimate relationships,
especially with opposite sex and family.
21. Relationships with Friends and Peers 0 1 2 3 4 5 U

The patient may have few or no friends
and may prefer to spend all his time
isolated.
22. Global Rating of Anhedonia/Asociality 0 1 2 3 4 5 U

This rating should reflect overall
severity, taking into account the
patient's age, family status, etc.
ATTENTION
23. Social Inattentiveness 0 1 2 3 4 5 U

The patient appears uninvolved or
unengaged. He may seem "spacey".
24. Inattentiveness During Mental Status 0 1 2 3 4 5 U

Testing
Refer to tests of "serial 7s" (at
least five subtractions) and spelling
"world" backwards.
25. Global Rating of Attention 0 1 2 3 4 5 U

This rating should assess the patient's
overall concentration, both clinically
and on tests.
SANS CODES
THE MOOD DISORDER QUESTIONNAIRE
Instructions: Please answer each question to the best of your ability.
YES NO
1. Has there ever been a period of time when you were not your usual self and...
...you felt so good or so hyper that other people thought you were not your " "
normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments? " "
...you felt much more self-confident than usual? " "
...you got much less sleep than usual and found you didn’t really miss it? " "
...you were much more talkative or spoke much faster than usual? " "
...thoughts raced through your head or you couldn’t slow your mind down? " "
...you were so easily distracted by things around you that you had trouble " "
concentrating or staying on track?
...you had much more energy than usual? " "
...you were much more active or did many more things than usual? " "
...you were much more social or outgoing than usual, for example, you " "
telephoned friends in the middle of the night?
...you were much more interested in sex than usual? " "
...you did things that were unusual for you or that other people might have " "
thought were excessive, foolish, or risky?
...spending money got you or your family into trouble? " "
2. If you checked YES to more than one of the above, have several of these " "
ever happened during the same period of time?
3. How much of a problem did any of these cause you – like being unable to
work; having family, money or legal troubles; getting into arguments or fights?
Please circle one response only.
No Problem Minor Problem Moderate Problem Serious Problem
4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, " "
aunts, uncles) had manic-depressive illness or bipolar disorder?
5. Has a health professional ever told you that you have manic-depressive illness " "
or bipolar disorder?
© 2000 by The University of Texas Medical Branch. Reprinted with permission. This instrument is designed for screening purposes only and is not to be used as a diagnostic tool.
SCORING THE MOOD DISORDER
QUESTIONNAIRE (MDQ)
The MDQ was developed by a team of psychiatrists, researchers and consumer advocates to address
a critical need for timely and accurate diagnosis of bipolar disorder, which can be fatal if left untreated.
The questionnaire takes about five minutes to complete, and can provide important insights into
diagnosis and treatment. Clinical trials have indicated that the MDQ has a high rate of accuracy; it is
able to identify seven out of ten people who have bipolar disorder and screen out nine out of ten
people who do not.1
A recent National DMDA survey revealed that nearly 70% of people with bipolar disorder had received
at least one misdiagnosis and many had waited more than 10 years from the onset of their symptoms
before receiving a correct diagnosis. National DMDA hopes that the MDQ will shorten this delay and
help more people to get the treatment they need, when they need it.
The MDQ screens for Bipolar Spectrum Disorder, (which includes Bipolar I, Bipolar II and
Bipolar NOS).
If the patient answers:
1. “Yes” to seven or more of the 13 items in question number 1;
AND
2. “Yes” to question number 2;
AND
3. “Moderate” or “Serious” to question number 3;
you have a positive screen. All three of the criteria above should be met. A positive screen should
be followed by a comprehensive medical evaluation for Bipolar Spectrum Disorder.
ACKNOWLEDGEMENT: This instrument was developed by a committee composed of the following individuals: Chairman,
Robert M.A. Hirschfeld, MD – University of Texas Medical Branch; Joseph R. Calabrese, MD – Case Western Reserve School
of Medicine; Laurie Flynn – National Alliance for the Mentally Ill; Paul E. Keck, Jr., MD – University of Cincinnati College of
Medicine; Lydia Lewis – National Depressive and Manic-Depressive Association; Robert M. Post, MD – National Institute of
Mental Health; Gary S. Sachs, MD – Harvard University School of Medicine; Robert L. Spitzer, MD – Columbia University;
Janet Williams, DSW – Columbia University and John M. Zajecka, MD – Rush Presbyterian-St. Luke’s Medical Center.
1 Hirschfeld, Robert M.A., M.D., Janet B.W. Williams, D.S.W., Robert L. Spitzer, M.D., Joseph R. Calabrese, M.D., Laurie Flynn, Paul E. Keck, Jr., M.D.,
Lydia Lewis, Susan L. McElroy, M.D., Robert M. Post, M.D., Daniel J. Rapport, M.D., James M. Russell, M.D., Gary S. Sachs, M.D., John Zajecka, M.D.,
“Development and Validation of a Screening Instrument for Bipolar Spectrum Disorder: The Mood Disorder Questionnaire.” American Journal of
Psychiatry 157:11 (November 2000) 1873-1875.
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
ID #:
NAME: DATE:
Over the last 2 weeks, how often have you been
bothered by any of the following problems?
Several More than Nearly
(use "ⁿ" to indicate your answer) Not at all half the every day
days days
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself or that you are a failure or 0 1 2 3

have let yourself or your family down
7. Trouble concentrating on things, such as reading the 0 1 2 3

newspaper or watching television
8. Moving or speaking so slowly that other people could

have noticed. Or the opposite being so figety or 0 1 2 3
restless that you have been moving around a lot more
than usual
9. Thoughts that you would be better off dead, or of 0 1 2 3

hurting yourself
add columns + +
(Healthcare professional: For interpretation of TOTAL, TOTAL:

please refer to accompanying scoring card).
10. If you checked off any problems, how difficult Not difficult at all
have these problems made it for you to do Somewhat difficult
your work, take care of things at home, or get
Very difficult
along with other people?
Extremely difficult
Copyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD© is a trademark of Pfizer Inc.
A2663B 10-04-2005
PHQ-9 Patient Depression Questionnaire
For initial diagnosis:
1. Patient completes PHQ-9 Quick Depression Assessment.

2. If there are at least 4 3s in the shaded section (including Questions #1 and #2), consider a depressive
disorder. Add score to determine severity.
Consider Major Depressive Disorder

- if there are at least 5 3s in the shaded section (one of which corresponds to Question #1 or #2)
Consider Other Depressive Disorder

- if there are 2-4 3s in the shaded section (one of which corresponds to Question #1 or #2)
Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician,
and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood
the questionnaire, as well as other relevant information from the patient.
Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social,
occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a
history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the
biological cause of the depressive symptoms.
To monitor severity over time for newly diagnosed patients or patients in current treatment for
depression:
1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at
home and bring them in at their next appointment for scoring or they may complete the
questionnaire during each scheduled appointment.
2. Add up 3s by column. For every 3: Several days = 1 More than half the days = 2 Nearly every day = 3
3. Add together column scores to get a TOTAL score.
4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.
5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of
response, as well as guiding treatment intervention.
Scoring: add up all checked boxes on PHQ-9
For every 3 Not at all = 0; Several days = 1;

More than half the days = 2; Nearly every day = 3
Interpretation of Total Score
Total Score Depression Severity

1-4 Minimal depression
5-9 Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depression
PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a
trademark of Pfizer Inc.
A2662B 10-04-2005
The Quality of Life in Bipolar Disorder (QoL.BD) Questionnaire
The following items ask about a range of experiences, behaviors and feelings related to quality of life. Please tell
us about your quality of life by rating how much you agree with each of the statements below. Circle the number
that best describes your experience over the last 7 days. Do not spend too long on each item, it is your first
impressions we are interested in.
Strongly disagree
Strongly agree
Disagree
Over the past 7 days, I have…
Neutral
Agree
1 Had plenty of energy 1 2 3 4 5
2 Had the right amount of exercise for me 1 2 3 4 5
3 Felt physically well 1 2 3 4 5
4 Been content with my sex life 1 2 3 4 5
5 Woken up feeling refreshed 1 2 3 4 5
6 Had no problems getting out of bed 1 2 3 4 5
7 Had about the right amount of sleep for me 1 2 3 4 5
8 Kept a routine in my sleep-wake schedule 1 2 3 4 5
9 Felt happy 1 2 3 4 5
10 Enjoyed things as much as I usually do 1 2 3 4 5
11 Felt able to cope 1 2 3 4 5
12 Felt emotionally balanced 1 2 3 4 5
13 Thought clearly 1 2 3 4 5
14 Had good concentration 1 2 3 4 5
15 Had no difficulties with my memory 1 2 3 4 5
16 Made plans without difficulty 1 2 3 4 5
17 Enjoyed my leisure activities 1 2 3 4 5
18 Been interested in my leisure activities 1 2 3 4 5
19 Had fun during my leisure activities 1 2 3 4 5
20 Expressed my creativity 1 2 3 4 5
21 Enjoyed spending time with other people 1 2 3 4 5
22 Been interested in my social relationships 1 2 3 4 5
23 Had meaningful friendships 1 2 3 4 5
24 Been able to share feelings or problems with a friend 1 2 3 4 5
25 Been satisfied with the spiritual side of my life 1 2 3 4 5
26 Expressed my spirituality as I wish 1 2 3 4 5
27 Practised my spirituality as I wish 1 2 3 4 5
28 Kept routine in my spiritual life 1 2 3 4 5
29 Had enough money for basic needs 1 2 3 4 5
30 Had enough money for extras 1 2 3 4 5
31 Felt secure about my current financial situation 1 2 3 4 5
32 Had no difficulties with debts 1 2 3 4 5
© Michalak and Murray 2009

Strongly disagree
Strongly agree
Disagree
Over the past 7 days, I have…
Neutral
Agree
33 Done my daily household chores 1 2 3 4 5
34 Been organized around my home 1 2 3 4 5
35 Kept my home tidy 1 2 3 4 5
36 Kept my home clean 1 2 3 4 5
37 Felt respected 1 2 3 4 5
38 Felt accepted by others 1 2 3 4 5
39 Felt as worthwhile as other people 1 2 3 4 5
40 Felt able to cope with stigma 1 2 3 4 5
41 Had a sense of freedom 1 2 3 4 5
42 Felt safe in my home environment 1 2 3 4 5
43 Traveled around freely (e.g., driving, using public transport) 1 2 3 4 5
44 Felt others have allowed me my independence 1 2 3 4 5
45 Had a strong sense of self 1 2 3 4 5
46 Had a stable sense of what I’m really like 1 2 3 4 5
47 Had a clear idea of what I want and don’t want 1 2 3 4 5
48 Had control over my life 1 2 3 4 5
Are you currently engaged in any paid or voluntary work? Please circle: Yes No
If yes -
49 Been confident in my abilities at work 1 2 3 4 5
50 Met demands at work 1 2 3 4 5
51 Been satisfied with the quality of my work 1 2 3 4 5
52 Been reliable at work 1 2 3 4 5
Are you currently engaged in any educational activities? Please circle: Yes No
If yes -
53 Enjoyed my educational activities 1 2 3 4 5
54 Felt confident about finishing my educational activities 1 2 3 4 5
55 Performed to my usual standards educationally 1 2 3 4 5
56 Organized my educational activities adequately 1 2 3 4 5
© Michalak and Murray 2009

P A T I E N T E D U C A T I O N T O O L S
Young Mania Rating Scale (YMRS)

OVERVIEW
The Young Mania Rating Scale (YMRS) is one of the most frequently utilized rating scales to assess manic symptoms. The
scale has 11 items and is based on the patient’s subjective report of his or her clinical condition over the previous 48
hours. Additional information is based upon clinical observations made during the course of the clinical interview. The
items are selected based upon published descriptions of the core symptoms of mania. The YMRS follows the style of the
Hamilton Rating Scale for Depression (HAM-D) with each item given a severity rating. There are four items that are
graded on a 0 to 8 scale (irritability, speech, thought content, and disruptive/aggressive behavior), while the remaining
seven items are graded on a 0 to 4 scale. These four items are given twice the weight of the others to compensate for poor
cooperation from severely ill patients. There are well described anchor points for each grade of severity. The authors
encourage the use of whole or half point ratings once experience with the scale is acquired. Typical YMRS baseline scores
can vary a lot. They depend on the patients’ clinical features such as mania (YMRS = 12), depression (YMRS = 3), or
euthymia (YMRS = 2). Sometimes a clinical study entry requirement of YMRS > 20 generates a mean YMRS baseline of
about 30. Strengths of the YMRS include its brevity, widely accepted use, and ease of administration. The usefulness of the
scale is limited in populations with diagnoses other than mania.
The YMRS is a rating scale used to evaluate manic symptoms at baseline and over time in individuals with mania.
The scale is generally done by a clinician or other trained rater with expertise with manic patients and takes 15–30
minutes to complete.
REFERENCES
Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133:429-435.
McIntyre RS, Mancini DA, Srinivasan J, McCann S, Konarski JZ, Kennedy SH. The antidepressant effects of risperidone and olanzapine in bipolar
disorder. Can J Clin Pharmacol. 2004;11:e218-226.
Young RC, Biggs JT, Ziegler VE, Meyer DA. Young Mania Rating Scale. In: Handbook of Psychiatric Measures. Washington, DC: American Psychiatric
Association; 2000:540-542.
Sponsored by Supported by an
educational grant from
www.MEASUREcme.org
GUIDE FOR SCORING ITEMS:
The purpose of each item is to rate the severity of that abnormality in the patient. When several keys are given for a
particular grade of severity, the presence of only one is required to qualify for that rating.
The keys provided are guides. One can ignore the keys if that is necessary to indicate severity, although this should be
the exception rather than the rule.
Scoring between the points given (whole or half points) is possible and encouraged after experience with the scale is
acquired. This is particularly useful when severity of a particular item in a patient does not follow the progression
indicated by the keys.
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
2. Increased Motor Activity-Energy

0 Absent
1 Subjectively increased
2 Animated; gestures increased
3 Excessive energy; hyperactive at times; restless (can be calmed)
4 Motor excitement; continuous hyperactivity (cannot be calmed)
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)
4. Sleep
0 Reports no decrease in sleep
1 Sleeping less than normal amount by up to one hour
2 Sleeping less than normal by more than one hour
3 Reports decreased need for sleep
4 Denies need for sleep
5. Irritability
0 Absent
2 Subjectively increased
4 Irritable at times during interview; recent episodes of anger or annoyance on ward
6 Frequently irritable during interview; short, curt throughout
8 Hostile, uncooperative; interview impossible
www.MEASUREcme.org
6. Speech (Rate and Amount)
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
7. Language-Thought Disorder
0 Absent
1 Circumstantial; mild distractibility; quick thoughts
2 Distractible, loses goal of thought; changes topics frequently; racing thoughts
3 Flight of ideas; tangentiality; difficult to follow; rhyming, echolalia
4 Incoherent; communication impossible
8. Content
0 Normal
2 Questionable plans, new interests
4 Special project(s); hyper-religious
6 Grandiose or paranoid ideas; ideas of reference
8 Delusions; hallucinations
9. Disruptive-Aggressive Behavior
0 Absent, cooperative
2 Sarcastic; loud at times, guarded
4 Demanding; threats on ward
6 Threatens interviewer; shouting; interview difficult
8 Assaultive; destructive; interview impossible
10. Appearance
0 Appropriate dress and grooming
1 Minimally unkempt
2 Poorly groomed; moderately disheveled; overdressed
3 Disheveled; partly clothed; garish make-up
4 Completely unkempt; decorated; bizarre garb
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
Reprinted with permission from The Royal College of Psychiatrists.
www.MEASUREcme.org
Rapid Mood Screener (RMS)
Are you among the millions of people who have depressive symptoms? Answer the
following questionnaire about your medical history and provide it to your doctor or nurse to
assist in an important conversation about your mood.
Please select one response for each question. You can complete the RMS in less than
2 minutes.
Patient Name _________________________________ Date ________________
YES NO
1. Have there been at least 6 different periods of time (at least 2 weeks)
when you felt deeply depressed?
2. Did you have problems with depression before the age of 18?
3. Have you ever had to stop or change your antidepressant because it

made you highly irritable or hyper?
4. Have you ever had a period of at least 1 week during which you were
more talkative than normal with thoughts racing in your head?
5. Have you ever had a period of at least 1 week during which you
felt any of the following: unusually happy; unusually outgoing; or
unusually energetic?
6. Have you ever had a period of at least 1 week during which you
needed much less sleep than usual?
RMS Copyright © 2020 AbbVie. All rights reserved.

AbbVie Medical
Rapid Mood Screener (RMS)
GUIDE FOR HEALTH CARE PROFESSIONALS
Approximately 70% of patients with bipolar I disorder (BP-I) are initially misdiagnosed,
with a mean delay of 5 to 10 years between illness onset and diagnosis. Most
commonly patients are misdiagnosed with major depressive disorder (MDD).1,2
The Rapid Mood Screener (RMS) was developed by a team of multidisciplinary experts
(primary care clinician, psychiatry nurse practitioner, psychiatrists, pharmacist,
behavioral therapists, psychometricians and health economists) to provide a pragmatic
approach to address the need for timely and accurate evaluation of bipolar disorder.
The screener was validated in a study of patients with BP-I and MDD.3
Clinical Utility
The RMS is a brief self-report screening instrument for BP-I that should take less than 2
minutes to complete. A positive screen should be followed by a comprehensive
evaluation.
Scoring & validity*

“YES” responses to 4 or more of the 6 items is considered a positive screen providing
high confidence for BP-I, with an estimated 88% sensitivity, 80% specificity, and 84%
accuracy
Sensitivity = percentage of patients who have BP-I disorder that are correctly identified
as positive
Specificity = percentage of patients who do not have BP-I and who are correctly
identified as negative
Accuracy = percentage of patients correctly predicted as BP-I or not
*“YES” to 3 or more of the 6 items also suggests a higher likelihood of BP-I than MDD with an estimated
97% sensitivity, 59% specificity, and 77% accuracy
1. Hirschfeld, RM et al. J Clin Psychiatry. 2003; 64(2):161-174.

2. Berk M, et al. J Affect Disord. 2007;103(1-3):181-186.
3. McIntyre RS, et al. Curr Med Res Opin. 2020 (in press).
RMS Copyright © 2020 AbbVie. All rights reserved.

AbbVie Medical
CLIENT NAME: DATE:
CLIENT ID#: MD:
BRIEF PSYCHIATRIC RATING SCALE (BPRS)
Please enter the score for the term which best describes the patient’s condition.
0 = not assessed, 1 = not present, 2 = very mild, 3 = mild, 4 = moderate, 5 = moderately severe, 6 = severe, 7 = extremely severe
1. SOMATIC CONCERN 10. HOSTILITY

Degree of concern over present bodily health. Rate the Animosity, contempt, belligerence, disdain for other people
degree to which physical health is perceived as a problem outside the interview situation. Rate solely on the basis of
by the patient, whether complaints have a realistic basis or SCORE the verbal report of feelings and actions of the patient SCORE
not. toward others; do not infer hostility from neurotic defenses,
anxiety, nor somatic complaints. (Rate attitude toward
interviewer under “uncooperativeness”).
2. ANXIETY 11. SUSPICIOUSNESS
Worry, fear, or over-concern for present or future. Rate Brief (delusional or otherwise) that others have now, or
solely on the basis of verbal report of patient’s own SCORE have had in the past, malicious or discriminatory intent SCORE
subjective experiences. Do not infer anxiety from physical toward the patient. On the basis of verbal report, rate only
signs or from neurotic defense mechanisms. those suspicions which are currently held whether they
concern past or present circumstances.
3. EMOTIONAL WITHDRAWAL 12. HALLUCINATORY BEHAVIOR
Deficiency in relating to the interviewer and to the Perceptions without normal external stimulus
interviewer situation. Rate only the degree to which the SCORE correspondence. Rate only those experiences which are SCORE
patient gives the impression of failing to be in emotional reported to have occurred within the last week and which
contact with other people in the interview situation. are described as distinctly different from the thought and
imagery processes of normal people.
4. CONCEPTUAL DISORGANIZATION 13. MOTOR RETARDATION
Degree to which the thought processes are confused, Reduction in energy level evidenced in slowed movements.
disconnected, or disorganized. Rate on the basis of SCORE Rate on the basis of observed behavior of the patient only; SCORE
integration of the verbal products of the patient; do not rate do not rate on the basis of patient’s subjective impression
on the basis of patient’s subjective impression of his own of own energy level.
level of functioning.
5. GUILT FEELINGS 14. UNCOOPERATIVENESS
Over-concern or remorse for past behavior. Rate on the Evidence of resistance, unfriendliness, resentment, and
basis of the patient’s subjective experiences of guilt as lack of readiness to cooperate with the interviewer. Rate
evidenced by verbal report with appropriate affect; do not SCORE only on the basis of the patient’s attitude and responses to SCORE
infer guilt feelings from depression, anxiety or neurotic the interviewer and the interview situation; do not rate on
defenses. basis of reported resentment or uncooperativeness outside
the interview situation.
6. TENSION 15. UNUSUAL THOUGHT CONTENT
SCORE
Physical and motor manifestations of tension “nervousness”, Unusual, odd, strange or bizarre thought content. Rate
and heightened activation level. Tension should be rated SCORE here the degree of unusualness, not the degree of
solely on the basis of physical signs and motor behavior and disorganization of thought processes.
not on the basis of subjective experiences of tension
reported by the patient.
7. MANNERISMS AND POSTURING 16. BLUNTED AFFECT
Unusual and unnatural motor benavior, the type of motor Reduced emotional tone, apparent lack of normal feeling or
behavior which causes certain mental patients to stand out SCORE involvement. SCORE
in a crowd of normal people. Rate only abnormality of

movements; do not rate simple heightened motor activity
here.
8. GRANDIOSITY 17. EXCITEMENT
Exaggerated self-opinion, conviction of unusual ability or SCORE Heightened emotional tone, agitation, increased reactivity. SCORE
powers. Rate only on the basis of patient’s statements about
himself or self-in-relation-to-others, not on the basis of his
demeanor in the interview situation.
9. DEPRESSIVE MOOD 18. DISORIENTATION
Despondency in mood, sadness. Rate only degree of SCORE Confusion or lack of proper association for person, place or SCORE
despondency; do not rate on the basis of inferences time.
concerning depression based upon general retardation and
somatic complaints.

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Sana Al Sehar

Riphah International University (GGC)

√) one answer for each of the questions below.

2. SLEEP DISTURBANCE: score either A or B

A: Insomnia (reduction in total sleep time)

B: Hypersomnia (increase in total sleep time, inclusive of daytime sleep)

3. APPETITE DISTURBANCE: score either A or B

5. REDUCED ENERGY AND ACTIVITY

0 Nil [normal motivation]

7. IMPAIRED CONCENTRATION AND MEMORY

12. HELPLESSNESS AND HOPELESSNESS

13. SUICIDAL IDEATION

15. PSYCHOTIC SYMPTOMS

18. INCREASED MOTOR DRIVE

0 Nil [normal motor drive]

19. INCREASED SPEECH

2. See things in a new and exciting light

3. Feel very creative with lots of ideas and plans

4. Become over-involved in new plans and projects

5. Become totally confident that everything you do will succeed

6. Feel that things are very vivid and crystal clear

7. Spend, or wish to spend, significant amounts of money

8. Find that your thoughts race

9. Notice lots of coincidences occurring

12. Feel one with the world and nature

13. Believe that things possess a ‘special meaning’

14. Say quite outrageous things

16. Feel irritated

17. Feel quite carefree, not worried about anything

20. Laugh more and find lots of things humorous

21. Read special significance into things

22. Talk over people

23. Have quite mystical experiences

24. Do fairly outrageous things

25. Sleep less and not feel tired

27. Feel angry

( ) This story fits me very well, or almost perfectly

Total score Likelihood of bipolar disorder (from Ghaemi)

Optimum threshold for positive diagnosis: score of 13 or above.

Sensitivity to Bipolar I & II: .75

Diagnostic Likelihood for Positive (DLR+): 10.7

CIDI-based Screening Scale for Bipolar Spectrum Disorders -

CIDI 3.0 Bipolar Screening Scales Scoring

The Scale has 12 Questions

2 Stem Questions: Question 1 & 2

1 Criterion B Screening Question: Question 3

9 Criterion B Symptom Questions

CIDI 3.0 Bipolar Screening Scales Scoring

Positive Predictive Values in sub-populations for CIDI-based Screening Scales

Number of For respondents For respondents For respondents

0 Questions = Y PPV = 0.0 PPV = 0.2 PPV = 0.0

CIDI-based Bipolar Disorder Screening Scale

Criterion B Screening Question

Criterion B Symptom Questions

Permission for use Ronald C Kessler, PhD

1. Unchanging Facial Expression 0 1 2 3 4 5 U

12. Increased Latency of Response 0 1 2 3 4 5 U

Patient Name _________________ Date