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Brief Psychiatric Rating Scale Expanded version 4.0: Scales anchor points and administration manual

Authors:
Version 4.0
BRIEF PSYCHIATRIC RATING SCALE
(BPRS)
Expanded Version
Scales, Anchor Points, and Administration Manual adapted by
Joseph Ventura, Ph.D., David Lukoff, Ph.D., Keith H. Nuechterlein,
Ph.D., Robert P. Liberman, M.D., Michael F. Green, Ph.D.,
and Andrew Shaner, M.D.
Clinical Research Center for Schizophrenia and Psychiatric
Rehabilitation
UCLA Department of Psychiatry and Biobehavioral Sciences
West Los Angeles VA Medical Center
February 19, 1993
Please use the following references for citation of the Expanded BPRS:
For Training and Quality Assurance program Version 4.0:
Ventura, J., Green, M.F., Shaner, A., Liberman, R.P. (1993) Training and Quality Assurance with the
Brief Psychiatric Rating Scale: "The Drift Busters." International Journal of Methods in
Psychiatric Research 3: 221-244.
Initial Version:
Lukoff, D., Nuechterlein, K.H., Ventura, J. (1986) Manual for the Expanded Brief Psychiatric Rating
Scale. Schizophrenia Bulletin 12: 594-602.
For Symptom Monitoring:
Lukoff, D., Liberman, R.P., and Nuechterlein, K.H. (1986) Symptom monitoring in the
rehabilitation of schizophrenic patients. Schizophrenia Bulletin 12:578-602.
DESCRIPTION AND ADMINISTRATION OF THE BPRS
The Brief Psychiatric Rating Scale (BPRS) provides a highly efficient, rapid
evaluation procedure for assessing symptom change in psychiatric patients. It yields
a comprehensive description of major symptom characteristics. Factor analyses of
the original 18-item BPRS typically yields four or five factor solutions. The Clinical
Research Center's Diagnosis and Psychopathology Unit has developed a 24-item
version of the BPRS.
This manual contains interview questions, symptom definitions, specific anchor
points for rating symptoms, and a "how to" section for problems that arise in rating
psychopathology. The purpose of the manual is to assist clinicians and researchers
to sensitively elicit psychiatric symptoms and to reliably rate the severity of
symptoms. The expanded BPRS includes six new scales added to the original BPRS
(Overall & Gorham, 1962) for the purpose of a more comprehensive assessment of a
wider range of individuals with serious mental disorders, especially outpatients living
in the community (Lukoff, Nuechterlein, & Ventura, 1986).
This manual will enable the clinician or researcher to conduct a high quality
interview adequate to the task of eliciting and rating the severity of symptoms in
individuals who are often inarticulate or who deny their illness. The following
guidelines are provided to standardize assessment. Please familiarize yourself with
these methods for assessing psychopathology.
(1) Using all sources of information on symptoms.
(2) Selecting an appropriate period or interval for rating symptoms.
(3) Integrating frequency and severity in symptom rating: the hierarchical criterion.
(4) Rating the severity of past delusions for which the patient lacks insight.
(5) Rating symptoms when the patient denies them.
(6) Using a standardized reference group in making ratings.
(7) Rating symptoms that overlap two or more categories or scales on the BPRS.
(8) Rating a symptom that has no specified anchor point congruent with its severity
level.
(9) "Blending" ratings made in different evaluation situations.
(10) Resolving apparently contradictory symptoms.
1. USING ALL SOURCES OF INFORMATION ON SYMPTOMS
Expanded BPRS Manual 2
The rating of psychopathology should be made on the basis of all available
sources of information about the patient. These sources include behavioral
observations and interviews made by treatment staff, family members, or other
caregivers in contact with the patient, available medical and psychiatric case
records, and the present interview of the patient. The interviewer/rater is encouraged
to seek additional sources of information about the patient's psychopathology from
others to supplement the present interview--this is particularly important when the
patient denies symptoms.
2. SELECTING AN APPROPRIATE PERIOD OR INTERVAL FOR RATING
SYMPTOMS
The duration of the time frame for assessment depends upon the purpose for the
rating. For example, if the rater is interested in determining the degree of change in
psychopathology during a one month period between pharmacotherapy visits, the
rating period should be one month. If a research protocol aims to evaluate the
emergence of prodromal symptoms or exacerbation of psychotic symptoms, it may
be advisable to select a one week interval since longer periods may lose accuracy in
retrospective recall. When a study demands completeness in identifying criteria for
relapse or exacerbation during a one or two year period, frequent BPRS assessments
will be necessary.
Rating periods typically range from one day to one month. Retrospective reporting
by patients beyond one month may suffer from response bias, retrospective
distortions, and memory problems (which are common in persons with psychotic and
affective disorders). When resources and personnel do not permit frequent
assessments, important information can still be captured if the frequency of
assessments can be temporarily increased when (1) prodromal symptoms or stress
are reported; (2) medication titration and dosing questions are paramount; and (3)
before and after major changes in treatment programs.
3. INTEGRATING FREQUENCY AND SEVERITY IN SYMPTOM RATING: THE
HIERARCHICAL CRITERION
Most of the BPRS scales are scored in terms of the frequency and/or severity of
the symptom. It is sometimes the case that the frequency and severity do not match.
A hierarchical principle should be followed that requires the rater to select the
highest scale level that applies to either frequency or severity. Thus, when the anchor
point definitions contain an "OR," the patient should be assigned the highest rating
that applies. For example, if a patient has hallucinations persistently throughout the
day (a rating of "7"), but the hallucinations only interfere with the patient's
functioning to a limited extent (a rating of "5"), the rater should score this scale "7."
The BPRS is suited to making frequent assessments of psychopathology covering
short periods of time. If, however, an interviewer intends to cover a relatively long
period of time (e.g., 6 weeks), then combining ratings for severity and frequency of
symptoms must be carefully thought out depending upon the specific project goals.
If the goal of a project is to define periods of relapse or exacerbation, the rating
should reflect the period of peak symptomatology. For example, if over a six week
period the patient experienced a week of persistent hallucinations, but was free of
hallucinations the remaining time, the patient should be rated a "6" on hallucinations,
reflecting the "worst" period of symptomatology. Alternatively, if the goal is to obtain
Expanded BPRS Manual 3
a general level of symptomatology, the rating should reflect a "blended" or average
score. For extended rating periods (e.g., 3 months), the interviewer may prefer to
make one rating reflecting the worst period of severity/frequency/functioning and
another rating reflecting the "average" amount of psychopathology for the entire
period.
4. RATING THE SEVERITY OF PAST DELUSIONS FOR WHICH THE SUBJECT
LACKS INSIGHT
Patients may often indicate varying degrees of insight or conviction regarding past
symptoms, making their symptoms difficult to rate. Experiences that result from
psychotic episodes can often appear quite real to patients. For example, the belief
that others tried to poison them, or controlled all their thoughts and forced them to
walk into traffic, could have created severe anxiety and intense fear. Patients can
give vivid accounts of their psychotic experiences that are as real as if the situations
actually occurred. It is important in these cases to rate the extent to which these
memories of a delusional experience can be separated from current delusions
involving the present.
Please note that a patient may be able to describe his or her past or current
delusions as part of an illness or even refer to them as "delusions." However, a
patient should always be rated as having delusions if he or she has acted on the
delusional belief during the rating period.
When a patient describes a delusional belief once firmly held, but that is now seen
as irrational, then a "1" should be scored for Unusual Thought Content (and also for
Grandiosity, Somatic Concern, Guilt, or Suspiciousness if the idea fell into one of
these thematic categories). However, if the individual still believes that the past
psychotic experience or event was real, despite not currently harboring the concern,
it should be rated a "2" or higher depending on the degree of reality distortion
associated with the belief.
Consider the following scenarios:
Scenario No. 1: The patient gives an account of delusional and/or hallucinatory
experience and realizes in retrospect that he was ill. He indicates that he has a
chemical imbalance in his brain, or that he has a mental condition.
Rate "1" on Unusual Thought Content.
Scenario No. 2: The patient gives indications that his past psychotic experiences
were due to a chemical imbalance and/or an illness, but entertains some degree of
doubt. He claims it is possible that people were trying to kill him, but he is doubtful.
The memories of what happened are not bizarre and he indicates that currently he is
certain no one is trying to hurt him.
Rate "2" or "3" on Unusual Thought Content depending on degree of reality
retained.
Scenario No. 3: The patient describes previous psychotic experiences as if they
actually occurred. He can give examples of what occurred, e.g., co-workers put drugs
in his coffee, or that machines read his thoughts. However, the patient says those
circumstances no longer occur. The patient is not currently concerned about
co-workers or machines, but he is convinced that the circumstances on which the
delusions are based actually occurred in the past.
Expanded BPRS Manual 4
Rate "3" or "4" on Unusual Thought Content depending on the degree of reality
distortion, and a "1" on Suspiciousness.
Scenario No. 4: The patient holds bizarre beliefs regarding the circumstances that
occurred in the past and/or his current behavior is influenced by delusional beliefs.
For example, the patient believes that thoughts were at one time beamed into his
mind from aliens OR the patient will not watch T.V. for fear that the messages will
again be directed to him OR that the mafia is located in shopping malls that he
should avoid.
Rate "4" or higher on Unusual Thought Content depending on the degree of
preoccupation and impairment associated with the belief. Consider rating
suspiciousness.
Scenario No. 5: The patient believes that previous psychotic experiences were real
and previous delusional beliefs are currently influencing most aspects of daily life
causing preoccupation and impairment.
Rate "6" or "7" on Unusual Thought Content depending on the degree of
preoccupation and impairment associated with the belief.
5. RATING SYMPTOMS WHEN THE PATIENT DENIES THEM
An all too common phenomenon in clinical practice or research is the denial or
minimization of symptoms by patients. Patients deny, hide, dissemble or minimize
their symptoms for a variety of reasons, including fear of being committed, restricted
to a hospital, or having medication increased. Simply recording a patient's negative
response to BPRS symptom items, if denial or distortion is present, will result in
invalid and unreliable data. When an interviewer suspects that a patient may be
denying symptoms, it is absolutely essential that other sources of information be
solicited and utilized in the ratings.
Several situations might suggest that a patient is not entirely forthcoming in
reporting his/her symptom experiences. Patients may deny hearing voices, yet be
observed whispering under their breath as if in response to a voice. The phrasing
that a patient uses in response to a direct question about a delusion or hallucination
can alert the interviewer to the potential denial of symptoms. For example, if a patient
responds to an inquiry regarding the presence of persecutory ideas by saying, "Not
really," this is not the same as saying "No." Subtleties in patient responses
communicate a great deal and must be followed-up before the interviewer concludes
that the symptom is absent.
There are several ways for the interviewer to obtain more reliable information from
a patient who may be denying or minimizing symptoms. In all these approaches,
interviewing skills, interpersonal rapport, and sensitivity to the patient are of
paramount importance. If the patient is experiencing difficulty disclosing information
about psychotic symptoms, the interviewer can shift to inquire about less threatening
material such as anxiety/depression or neutral topics. The interviewer should then
return to sensitive topics after the patient feels more comfortable and concerns
about disclosure have been addressed.
The use of empathy is critical in helping a patient express difficult and possibly
Expanded BPRS Manual 5
embarrassing experiences. A interviewer may say, "l understand that recalling what
happened may be unpleasant, but I am very interested in exactly what you
experienced." It is advisable to let patients know what you may be sensing clinically;
"I have the impression that you are reluctant to tell me more about what happened.
Could that be because you are concerned about what I might think or write down
about you?" The interviewer should actively engage the patient in discussing any
apparent reasons for denying symptoms. The interviewer can discuss openly in an
inviting and noncritical fashion any discrepancies noted between the patient's
self-report of symptoms and observations of speech and behavior. For example, "You
have said that you are not depressed, yet you seem very sad and you have been
moving very slowly." When denial occurs, the BPRS interview becomes a dynamic
interplay between the interviewer's desire for accurate symptom information and
determining the reasons underlying the patient's reluctance to disclose.
Occasionally, at the time of the interview, the interviewer will have information
about the symptoms that the patient is denying. It is permissible to use a mild
confrontation technique in an attempt to encourage a patient to disclose accurate
symptom information. For example, a BPRS interviewer may learn from the patient's
therapist or relatives of the presence of auditory hallucinations. The interviewer may
state, "I understand from talking with your therapist (or relative) that you have been
hearing voices. Could you tell me about that?" Letting the patient know in a sensitive
and gentle manner that information about his symptoms are already known may aid
willingness to disclose. This approach is most effective when a policy of sharing
patient information in a treatment team situation is explained to all entering patients.
In may be necessary to inform the patient that not all clinical material is shared, but
that symptom information needed to manage treatment cannot in all cases be
confidential.
When you cannot resolve conflicts or contradictions between patient's self-report
and the report of others, you must use your clinical judgment regarding the most
reliable informants. Be sure to make notes on the BPRS rating sheet regarding any
conflicting sources of information and specify how the final decision was made.
6. USING A STANDARDIZED REFERENCE GROUP IN MAKING RATINGS
The proper reference group for conducting assessments is a group of normal
individuals who are not psychiatric patients who are living and working in the
community free of symptoms. BPRS interviewers should have in mind a group of
individuals who are able to function either at work/school, socially, or as a
homemaker, at levels appropriate to the patient's age and socioeconomic status.
Research has shown that normal controls score at "2" or below on most psychotic
items of the BPRS. BPRS interviewers should not use other patients previously
interviewed, especially those with severe symptoms, as the reference standard,
since this will systematically bias ratings toward lower scores.
7. RATING SYMPTOMS THAT OVERLAP TWO OR MORE CATEGORIES OR
SCALES ON THE BPRS
Systematized or multiple delusions can be rated on more than one symptom item
or scale on the BPRS. depending on the theme of the delusional belief. For example,
if a
Expanded BPRS Manual 6
patient has a delusion that certain body parts have been surgically removed
against his/her will and replaced with broken mechanical parts, he or she would
be rated at the level of "6" or "7" on both Somatic Concern and at the level of "4"
to "7" on Unusual Thought Content depending on the frequency and
preoccupation with the delusion. Furthermore, if the patient felt guilty because he
believed the metal in his body interfered with radio transmissions between air
traffic controllers and pilots resulting in several plane crashes, the BPRS item
Guilt should also be rated.
The specific ratings for each of the overlapping symptom dimensions may differ
depending on the anchor points of the BPRS item(s). Thus, a patient with a clear-cut
persecutory delusion involving the neighbors should be rated a "6" on
Suspiciousness. Whereas, the same delusion could be rated a "4" on Unusual
Thought Content if it is encapsulated and not associated with impairment.
8. RATING A SYMPTOM THAT HAS NO SPECIFIC ANCHOR POINT CONGRUENT
WITH ITS SEVERITY LEVEL
The anchor points for a given BPRS item are critical in achieving good reliability
across raters and across research settings. However, there are occasions when a
particular symptom may not fit any of the anchor point definitions. Anchor point
definitions could not be written to cover all possible symptoms exhibited by patients.
In general, ratings of 2 or 3 represent nonpathological but observable mild
symptomatology; 4 or 5 represents clinically significant moderate symptomatology;
and 6 or 7 represents clinically significant and severe symptomatology.
The anchor points in this manual are guidelines to aid in the process of defining
the character, frequency, and impairment associated with various types of
psychiatric symptoms. When faced with a complicated rating, the interviewer may
find it useful to first classify the symptom as mild (2 or 3), moderate (4 or 5), or
severe (6 or 7), and second to consult the anchor point definitions to pinpoint the
rating.
BPRS symptoms that are classified in the severe range usually represent
pathological phenomena. However, it is possible for a patient to report or be
observed to exhibit examples of mild psychopathology that should be rated at much
higher levels. For example, on the item Tension, if hand wringing is observed on 2-3
occasions, the interviewer would rate a "2" or "3." However, if the patient is observed
to be hand wringing constantly, then consider a higher rating such as "5" or "6" on
Tension. Similarly, instances of severe psychopathology that are brief, transient, and
non-impairing in nature should be rated in the mild range.
9. "BLENDING" RATINGS MADE IN DIFFERENT EVALUATION SITUATIONS
A psychiatric patient can exhibit different levels of the same symptom depending
on the setting in which the patient is observed or the time period involved. Consider
the patient who is talkative during a rating session with the BPRS interviewer, but is
very withdrawn and blunted with other patients. In the interview session the patient
may rate a "3" on blunted affect and "2" on emotional withdrawal, but rate "5" on
those symptoms when interacting with other patients. The interviewer can consider
integrating the two sources of information and make an averaged or "blended" rating.
Expanded BPRS Manual 7
10. RESOLVING APPARENTLY CONTRADICTORY SYMPTOMS
It is possible to rate two or more symptoms on the BPRS that represent seemingly
contradictory dimensions of phenomenology. For example, a patient can exhibit
blunted affect and elevated mood in the same interview period. A patient may laugh
and joke with the interviewer, but then shift to a blunted, slowed, and emotionally
withdrawn state during the same interview. In this case, rating the presence of both
elevated mood and negative symptoms may be appropriate reflecting that both mood
states were present. Although the simultaneous presence of apparently contradictory
symptoms is rare, if such combinations do appear, the rater should consider rating
each symptom lower than if just one had appeared. This conservative approach to
rating reflects a cautious orientation to the rating process when there is ambiguity
regarding the symptomatology being assessed.
CLINICAL APPLICATIONS OF THE BPRS: GRAPHING SYMPTOMS
A graph is printed at the end of this administration manual to help raters plot and
monitor symptoms from the BPRS. Because psychotic and other symptoms often
fluctuate over time, graphing them enables the clinician to identify exacerbations,
periods of remission, and prodromal periods that precede a relapse. Monitoring and
graphing can be the key to early intervention to reduce morbidity, relapses, and
rehospitalizations.
Graphing of symptomatology can provide vivid representations of the
relationships between specific types of symptoms (e.g., hallucinations) and other
variables of interest, such as (1) medication type and dose, (2) changes in
psychosocial treatment and rehabilitation programs, (3) the use of "street" drugs or
alcohol, (4) life events, and (5) other environmental or familial stressors. The
preprinted graph shown at the end of this manual provides space to write significant
life events or treatment changes and permits the "eyeballing" of the influence of
these variables on symptoms. Repeated measurement and graphing of symptoms
over time can be done for individual items (e.g., anxiety or hallucinations), or for
clusters of symptoms (e.g., psychotic index). Such clusters can be chosen from
factor analyses of earlier versions of the BPRS (Guy, 1976; Overall, Hollister, and
Pichot, 1967; Overall and Porterfield, 1963). The blank graph in this manual allows
raters to select and write in specific symptoms of the BPRS based on the needs of
individual patients.
REFERENCES
Guy W: ECDEU Assessment Manual for Psychopharmacology. DHEW Pub. No.
(ADM) 76-338. Rockville, MD: National Institute of Mental Health, 1976.
Lukoff D, Nuechterlein KH, and Ventura J: Manual for the Expanded Brief Psychiatric
Rating Scale. Schizophrenia Bulletin, 12: 594-602, 1986.
Overall JE and Gorham DR, The Brief Psychiatric Rating Scale. Psychological
Reports, 10: 799-812, 1962.
Overall JE, Hollister LE, Pichot P: Major psychiatric disorders: A four-dimensional
model. Archives of General Psychiatry, 16: 146-151, 1967.
Expanded BPRS Manual 8
Overall JE and Porterfield, JL. Powered vector method of factor analysis.
Psychometrika, 28: 415-422, 1963
Expanded BPRS Manual 9
SCALE ITEMS AND ANCHOR POINTS
Rate items 1-14 on the basis of patient's self-report. Note items 7, 12, and 13
are also rated on the basis of observed behavior. Items 15-24 are rated on the
basis of observed behavior and speech.
1. SOMATIC CONCERN: Degree of concern over present bodily health.
Rate the degree to which physical health is perceived as a problem by
the patient, whether complaints have realistic bases or not. Somatic
delusions should be rated in the severe range with or without somatic
concern. Note: Be sure to assess the degree of impairment due to
somatic concerns only and not other symptoms, e.g., depression. In
addition, if the subject rates a "6" or "7" due to somatic delusions, then
you must rate Unusual Thought Content at least a "4" or above.
Have you been concerned about your physical health? Have you had
any physical illness or seen a medical doctor lately? (What does your
doctor say is wrong? How serious is it?
Has anything changed regarding your appearance?
Has it interfered with your ability to perform your usual activities and/or
work?
Did you ever feel that parts of your body had changed or stopped
working?
[If patient reports any somatic concerns/delusions, ask the following]:
How often are you concerned about [use patient's description]?
Have you expressed any of these concerns to others?
2 Very Mild
Occasional somatic concerns that tend to be kept to self.
3 Mild
Occasional somatic concerns that tend to be voiced to
others (e.g., family, physician).
4 Moderate
Frequent expressions of somatic concern or
exaggerations of existing ills OR some preoccupation, but
no impairment in functioning. Not delusional.
5 Moderately Severe
Frequent expressions of somatic concern or exaggeration
of existing ills OR some preoccupation and moderate
impairment of functioning. Not delusional
6 Severe
Preoccupation with somatic complaints with much
impairment in functioning OR somatic delusions without
acting on them or disclosing to others.
7 Extremely Severe
Preoccupation with somatic complaints with severe
impairment in functioning OR somatic delusions that tend
to be acted on or disclosed to others.
2. ANXIETY: Reported apprehension, tension, fear, panic or worry. Rate only the
patient's statements, not observed anxiety which is rated under TENSION.
Have you been worried a lot during [mention time frame]? Have you been nerv-
ous or apprehensive? (What do you worry about?) Are you concerned about
anything? How about finances or the future? When you are feeling nervous, do
your palms sweat or does your heart beat fast (or shortness of breath,
trembling, choking)?
[If patient reports anxiety or autonomic accompaniment, ask the following]:
How much of the time have you been [use patient's description]?
Has it interfered with your ability to perform your usual activities/work?
2 Very Mild
Reports some discomfort due to worry OR infrequent worries that
occur more than usual for most normal individuals.
3 Mild
Worried frequently but can readily turn attention to other things.
4 Moderate
Worried most of the time and cannot turn attention to other things
easily but no impairment in functioning OR occasional anxiety
with autonomic accompaniment but no impairment in functioning.
5 Moderately Severe
Frequent, but not daily, periods of anxiety with autonomic
accompaniment OR some areas of functioning are disrupted by
anxiety or worry.
6 Severe
Anxiety with autonomic accompaniment daily but not persisting
throughout the day OR many areas of functioning are disrupted
by anxiety or constant worry.
7 Extremely Severe
Anxiety with autonomic accompaniment persisting throughout
the day OR most areas of functioning are disrupted by anxiety or
constant worry.
3. DEPRESSION: Include sadness, unhappiness, anhedonia, and preoccupation
with depressing topics (can't attend to TV or conversations due to
depression), hopelessness, loss of self-esteem (dissatisfied or disgusted with
self or feelings of worthlessness). Do not include vegetative symptoms, e.g.,
motor retardation, early waking, or the amotivation that accompanies the
deficit syndrome.
How has your mood been recently? Have you felt depressed (sad, down,
unhappy as if you didn't care)? Are you able to switch your attention to more
pleasant topics when you want to? Do you find that you have lost interest in
or get less pleasure from things you used to enjoy, like family, friends,
hobbies, watching TV, eating?
[If subject reports feelings of depression, ask the following]:
How long do these feelings last? Has it interfered with your ability to perform
your usual activities/work?
2 Very Mild
Occasionally feels sad, unhappy or depressed.
3 Mild
Frequently feels sad or unhappy but can readily turn attention to other
things.
4 Moderate
Frequent periods of feeling very sad, unhappy, moderately
depressed, but able to function with extra effort.
5 Moderately Severe
Frequent, but not daily, periods of deep depression OR some
areas of functioning are disrupted by depression.
6 Severe
Deeply depressed daily but not persisting throughout the day OR
many areas of functioning are disrupted by depression.
7 Extremely Severe
Deeply depressed daily OR most areas of functioning are
disrupted by depression.
4. SUICIDALITY: Expressed desire, intent or actions to harm or kill self.
Have you felt that life wasn't worth living? Have you thought about harming or
killing yourself? Have you felt tired of living or as though you would be better
off dead? Have you ever felt like ending it all?
[If patient reports suicidal ideation, ask the following]:
How often have you thought about [use patient's description]?
Did you (Do you) have a specific plan?
2 Very Mild
Occasional feelings of being tired of living. No overt suicidal
thoughts.
3 Mild
Occasional suicidal thoughts without intent or specific plan OR
he/she feels they would be better off dead.
4 Moderate
Suicidal thoughts frequent without intent or plan.
5 Moderately Severe
Many fantasies of suicide by various methods. May seriously
consider making an attempt with specific time and plan OR
impulsive suicide attempt using non-lethal method or in full view
of potential saviors.
6 Severe
Clearly wants to kill self. Searches for appropriate means and
time, OR potentially serious suicide attempt with patient
knowledge of possible rescue.
7 Extremely Severe
Specific suicidal plan and intent (e.g., "as soon as ________ I will
do it by doing X"), OR suicide attempt characterized by plan
patient thought was lethal or attempt in secluded environment.
5. GUILT: Over concern or remorse for past behavior. Rate only patient's
statements, do not infer guilt feelings from depression, anxiety, or neurotic
defenses. Note: If the subject rates a "6" or "7" due to delusions of guilt, then
you must rate Unusual Thought Content at least a "4" or above depending on
level of preoccupation and impairment.
Is there anything you feel guilty about? Have you been thinking about past
problems? Do you tend to blame yourself for things that have happened?
Have you done anything you're still ashamed of?
[If patient reports guilt/remorse/delusions, ask the following]:
How often have you been thinking about [use patient's description]?
Have you disclosed your feelings of guilt to others?
2 Very Mild
Concerned about having failed someone or at something but not
preoccupied.
Can shift thoughts to other matters easily.
3 Mild
Concerned about having failed someone or at something with
some preoccupation. Tends to voice guilt to others.
4 Moderate
Disproportionate preoccupation with guilt, having done wrong,
injured others by doing or failing to do something, but can readily
turn attention to other things.
5 Moderately Severe
Preoccupation with guilt, having failed someone or at something,
can turn attention to other things, but only with great effort. Not
delusional.
6 Severe
Delusional guilt OR unreasonable self-reproach very out of proportion
to circumstances. Moderate preoccupation present.
7 Extremely Severe
Delusional guilt OR unreasonable self-reproach grossly out of
proportion to circumstances. Subject is very preoccupied with
guilt and is likely to disclose to others or act on delusions.
6. HOSTILITY: Animosity, contempt, belligerence, threats, arguments, tantrums,
property destruction, fights and any other expression of hostile attitudes or
actions. Do not infer hostility from neurotic defenses, anxiety or somatic
complaints. Do not include incidents of appropriate anger or obvious
self-defense.
How have you been getting along with people (family, co- workers, etc.)?
Have you been irritable or grumpy lately? (How do you show it? Do you
keep it to yourself?) Were you ever so irritable that you would shout at
people or start fights or arguments? (Have you found yourself yelling at
people you didn't know?) Have you hit anyone recently?
2 Very Mild
Irritable or grumpy, but not overtly expressed.
3 Mild
Argumentative or sarcastic.
4 Moderate
Overtly angry on several occasions OR yelled at others
excessively.
5 Moderately Severe
Has threatened, slammed about or thrown things.
6 Severe
Has assaulted others but with no harm likely, e.g., slapped or
pushed, OR destroyed property, e.g., knocked over furniture,
broken windows.
7 Extremely Severe
Has attacked others with definite possibility of harming them or
with actual harm, e.g., assault with hammer or weapon.
7. ELEVATED MOOD: A pervasive, sustained and exaggerated feeling of
well-being, cheerfulness, euphoria (implying a pathological mood), optimism
that is out of proportion to the circumstances. Do not infer elation from
increased activity or from grandiose statements alone.
Have you felt so good or high that other people thought that you were not your
normal self? Have you been feeling cheerful and "on top of the world" without
any reason?
[If patient reports elevated mood/euphoria, ask the following]:
Did it seem like more than just feeling good? How long did that last?
2 Very Mild
Seems to be very happy, cheerful without much reason.
3 Mild
Some unaccountable feelings of well-being that persist.
4 Moderate
Reports excessive or unrealistic feelings of well-being, cheerful-
ness, confidence or optimism inappropriate to circumstances,
some of the time. May frequently joke, smile, be giddy or overly
enthusiastic OR few instances of marked elevated mood with
euphoria.
5 Moderately Severe
Reports excessive or unrealistic feelings of well-being,
confidence or optimism inappropriate to circumstances much of
the time. May describe feeling on top of the world," "like
everything is falling into place," or "better than ever before," OR
several instances of marked elevated mood with euphoria.
6 Severe
Reports many instances of marked elevated mood with euphoria
OR mood definitely elevated almost constantly throughout
interview and inappropriate to content
7 Extremely Severe
Patient reports being elated or appears almost intoxicated, laugh-
ing, joking, giggling, constantly euphoric, feeling invulnerable, all
inappropriate to immediate circumstances.
8. GRANDIOSITY: Exaggerated self-opinion, self-enhancing conviction of special
abilities or powers or identity as someone rich or famous. Rate only patient's
statements about himself, not his demeanor. Note: If the subject rates a "6" or
"7" due to grandiose delusions, you must rate Unusual Thought Content at
least a "4" or above.
Is there anything special about you? Do you have any special abilities or
powers? Have you thought that you might be somebody rich or famous?
[If the patient reports any grandiose ideas/delusions, ask the following]:
How often have you been thinking about [use patient's description]? Have you
told anyone about what you have been thinking? Have you acted on any of
these ideas?
2 Very Mild
Feels great and denies obvious problems, but not unrealistic.
3 Mild
Exaggerated self-opinion beyond abilities and training.
4 Moderate
Inappropriate boastfulness claims to be brilliant, insightful, or
gifted beyond realistic proportions, but rarely self-discloses or
acts on these inflated self-concepts. Does not claim that
grandiose accomplishments have actually occurred.
5 Moderately Severe
Same as 4 but often self-discloses and acts on these grandiose
ideas. May have doubts about the reality of the grandiose ideas.
Not delusional.
6 Severe
Delusional--claims to have special powers like ESP, to have
millions of dollars, invented new machines, worked at jobs when
it is known that he was never employed in these capacities, be
Jesus Christ, or the President. Patient may not be very
preoccupied.
7 Extremely Severe
Delusional--Same as 6 but subject seems very preoccupied and
tends to disclose or act on grandiose delusions.
9. SUSPICIOUSNESS: Expressed or apparent belief that other persons have acted
maliciously or with discriminatory intent. Include persecution by supernatural or
other nonhuman agencies (e.g., the devil). Note: Ratings of "3" or above should also
be rated under Unusual Thought Content.
Do you ever feel uncomfortable in public? Does it seem as though others are
watching you? Are you concerned about anyone's intentions toward you? Is
anyone going out of their way to give you a hard time, or trying to hurt you? Do
you feel in any danger?
[If patient reports any persecutory ideas/delusions, ask the following]:
How often have you been concerned that [use patient's description]? Have you told
anyone about these experiences?
2 Very Mild
Seems on guard. Reluctant to respond to some "personal"
questions. Reports being overly self-conscious in public.
3 Mild
Describes incidents in which others have harmed or wanted to
harm him/her that sound plausible. Patient feels as if others are
watching, laughing, or criticizing him/her in public, but this
occurs only occasionally or rarely. Little or no preoccupation.
4 Moderate
Says others are talking about him/her maliciously, have negative
intentions, or may harm him/her. Beyond the likelihood of
plausibility, but not delusional. Incidents of suspected
persecution occur occasionally (less than once per week) with
some preoccupation.
5 Moderately Severe
Same as 4, but incidents occur frequently, such as more than
once per week. Patient is moderately preoccupied with ideas of
persecution OR patient reports persecutory delusions expressed
with much doubt (e.g., partial delusion).
6 Severe
Delusional -- speaks of Mafia plots, the FBI, or others poisoning
his/her food, persecution by supernatural forces.
7 Extremely Severe
Same as 6, but the beliefs are bizarre or more preoccupying.
Patient tends to disclose or act on persecutory delusions.
10. HALLUCINATIONS: Reports of perceptual experiences in the absence of relevant
external stimuli. When rating degree to which functioning is disrupted by hal-
lucinations, include preoccupation with the content and experience of the hal-
lucinations, as well as functioning disrupted by acting out on the hallucinatory
content (e.g., engaging in deviant behavior due to command hallucinations). Include
thoughts aloud ("gedankenlautwerden") or pseudohallucinations (e.g., hears a voice
inside head) if a voice quality is present.
Do you ever seem to hear your name being called? Have you heard any sounds or
people talking to you or about you when there has been nobody around? [If hears
voices]: What does the voice/voices say? Did it have a voice quality? Do you ever
have visions or see things that others do not see? What about smell odors that
others do not smell?
[If the patient reports hallucinations, ask the following]:
Have these experiences interfered with your ability to perform your usual
activities/work? How do you explain them? How often do they occur?
2 Very Mild
While resting or going to sleep, sees visions, smells odors, or
hears voices, sounds or whispers in the absence of external
stimulation, but no impairment in functioning.
3 Mild
While in a clear state of consciousness, hears a voice calling the
subjects name, experiences non-verbal auditory hallucinations
(e.g., sounds or whispers), formless visual hallucinations, or has
sensory experiences in the presence of a modality-relevant
stimulus (e.g., visual illusions) infrequently (e.g., 1-2 times per
week) and with no functional impairment.
4 Moderate
Occasional verbal, visual, gustatory, olfactory, or tactile
hallucinations with no functional impairment OR non-verbal
auditory hallucinations/visual illusions more than infrequently or
with impairment.
5 Moderately Severe
Experiences daily hallucinations OR some areas of functioning
are disrupted by hallucinations.
6 Severe
Experiences verbal or visual hallucinations several times a day
OR many areas of functioning are disrupted by these
hallucinations.
7 Extremely Severe
Persistent verbal or visual hallucinations throughout the day OR
most areas of functioning are disrupted by these hallucinations.
11. UNUSUAL THOUGHT CONTENT: Unusual, odd, strange or bizarre thought content.
Rate the degree of unusualness, not the degree of disorganization of speech.
Delusions are patently absurd, clearly false or bizarre ideas that are expressed with
full conviction. Consider the patient to have full conviction if he/she has acted as
though the delusional belief were true. Ideas of reference/persecution can be
differentiated from delusions in that ideas are expressed with much doubt and
contain more elements of reality. Include thought insertion, withdrawal and
broadcast. Include grandiose, somatic and persecutory delusions even if rated
elsewhere. Note: if Somatic Concern, Guilt, Suspiciousness, or Grandiosity are
rated "6" or "7" due to delusions, then Unusual Thought Content must be rated a
"4" or above.
Have you been receiving any special messages from people or from the way
things are arranged around you? Have you seen any references to yourself on
TV or in the newspapers? Can anyone read your mind? Do you have a special
relationship with God? Is anything like electricity, X- rays, or radio waves
affecting you? Are thoughts put into your head that are not your own? Have
you felt that you were under the control of another person or force?
[If patient reports any odd ideas/delusions, ask the following]:
How often do you think about [use patient's description]? Have you told
anyone about these experiences? How do you explain the things that have
been happening [specify]?
2 Very Mild
Ideas of reference (people may stare or may laugh at him), ideas
of persecution (people may mistreat him). Unusual beliefs in
psychic powers, spirits, UFO's, or unrealistic beliefs in one's own
abilities. Not strongly held. Some doubt.
3 Mild
Same as 2, but degree of reality distortion is more severe as
indicated by highly unusual ideas or greater conviction.
Content may be typical of delusions (even bizarre), but without
full conviction. The delusion does not seem to have fully
formed, but is considered as one possible explanation for an
unusual experience.
4 Moderate
Delusion present but no preoccupation or functional impairment.
May be an encapsulated delusion or a firmly endorsed absurd
belief about past delusional circumstances.
5 Moderately Severe
Full delusion(s) present with some preoccupation OR some areas
of functioning disrupted by delusional thinking.
6 Severe
Full delusion(s) present with much preoccupation OR many areas
of functioning are disrupted by delusional thinking.
7 Extremely Severe
Full delusions present with almost total preoccupation OR most
areas of functioning are disrupted by delusional thinking.
Rate items 12-13 on the basis of patient's self-report and observed behavior.
12. BIZARRE BEHAVIOR: Reports of behaviors which are odd, unusual, or
psychotically criminal. Not limited to interview period. Include inappropriate
sexual behavior and inappropriate affect.
Have you done anything that has attracted the attention of others?
Have you done anything that could have gotten you into trouble with the
police? Have you done anything that seemed unusual or disturbing to others?
2 Very Mild
Slightly odd or eccentric public behavior, e.g., occasionally
giggles to self, fails to make appropriate eye contact, that does
not seem to attract the attention of others OR unusual behavior
conducted in private, e.g., innocuous rituals, that would not
attract the attention of others.
3 Mild
Noticeably peculiar public behavior, e.g., inappropriately loud
talking, makes inappropriate eye contact, OR private behavior
that occasionally, but not always, attracts the attention of
others, e.g., hoards food, conducts unusual rituals, wears
gloves indoors.
4 Moderate
Clearly bizarre behavior that attracts or would attract (if done
privately) the attention or concern of others, but with no
corrective intervention necessary. Behavior occurs occasionally,
e.g., fixated staring into space for several minutes, talks back to
voices once, in appropriate giggling/laughter on 1-2 occasions,
talking loudly to self.
5 Moderately Severe
Clearly bizarre behavior that attracts or would attract (if done
privately) the attention of others or the authorities, e.g., fixated
staring in a socially disruptive way, frequent inappropriate
giggling/laughter, occasionally responds to voices, or eats non-
foods.
6 Severe
Bizarre behavior that attracts attention of others and intervention
by authorities, e.g., directing traffic, public nudity, staring into
space for long periods, carrying on a conversation with
hallucinations, frequent inappropriate giggling/laughter.
7 Extremely Severe
Serious crimes committed in a bizarre way that attracts the
attention of others and the control of authorities e.g., sets fires
and stares at flames OR almost constant bizarre behavior, e.g.,
inappropriate giggling/laughter, responds only to hallucinations
and cannot be engaged in interaction.
13. SELF-NEGLECT: Hygiene, appearance, or eating behavior below usual
expectations, below socially acceptable standards, or life-threatening.
How has your grooming been lately? How often do you change your clothes?
How often do you take showers? Has anyone (parents/staff) complained about
your grooming or dress? Do you eat regular meals?
2 Very Mild
Hygiene/appearance slightly below usual community standards,
e.g., shirt out of pants, buttons unbuttoned, shoelaces untied, but
no social or medical consequences.
3 Mild
Hygiene/appearance occasionally below usual community
standards, e.g., irregular bathing, clothing is stained, hair
uncombed, occasionally skips an important meal. No social or
medical consequences
4 Moderate
Hygiene/appearance is noticeably below usual community
standards, e.g., fails to bathe or change clothes, clothing very
soiled, hair unkempt, needs prompting, noticeable by others OR
irregular eating and drinking with minimal medical concerns and
consequences.
5 Moderately Severe
Several areas of hygiene/appearance are below usual community
standards OR poor grooming draws criticism by others, and
requires regular prompting. Eating or hydration is irregular and
poor, causing some medical problems.
6 Severe
Many areas of hygiene/appearance are below usual community
standards, does not always bathe or change clothes even if
prompted. Poor grooming has caused social ostracism at
school/residence/work, or required intervention. Eating erratic
and poor, may require medical intervention.
7 Extremely Severe
Most areas of hygiene/appearance/nutrition are extremely poor
and easily noticed as below usual community standards OR
hygiene/appearance/nutrition requires urgent and immediate
medical intervention.
14. DISORIENTATION: Does not comprehend situations or communications,
such as questions asked during the entire BPRS interview. Confusion
regarding person, place, or time. Do not rate if incorrect responses are due
to delusions.
May I ask you some standard questions we ask everybody?
How old are you? What is the date (allow + or - 2 days)? What is this place
called? What year were you born? Who is the president?
2 Very Mild
Seems muddled or mildly confused 1-2 times during interview.
Oriented to person, place, and time.
3 Mild
Occasionally muddled or mildly confused 3-4 times during
interview. Minor inaccuracies in person, place, or time, e.g., date
off by more than + or - 2 days, or gives wrong division of hospital.
4 Moderate
Frequently confused during interview. Minor inaccuracies in
person, place, or time are noted, as in "3" above. In addition, may
have difficulty remembering general information, e.g., name of
president.
5 Moderately Severe
Markedly confused during interview, or to person, place, or time.
Significant inaccuracies are noted, e.g., date off by more than one
week, or cannot give correct name of hospital. Has difficulty
remembering personal information, e.g., where he/she was
born, or recognizing familiar people.
6 Severe
Disoriented to person, place, or time, e.g., cannot give correct
month and year. Disoriented in 2 out of 3 spheres.
7 Extremely Severe
Grossly disoriented to person, place, or time, e.g., cannot give
name or age. Disoriented in all 3 spheres.
Rate items 15-24 on the basis of observed behavior and speech.
15. CONCEPTUAL DISORGANIZATION: Degree to which speech is confused,
disconnected, vague or disorganized. Rate tangentiality, circumstantiality,
sudden topic shifts, incoherence, derailment, blocking, neologisms, and other
speech disorders. Do not rate content of speech.
2 Very Mild
Peculiar use of words or rambling but speech is comprehensible.
3 Mild
Speech a bit hard to understand or make sense of due to
tangentiality, circumstantiality or sudden topic shifts.
4 Moderate
Speech difficult to understand due to tangentiality,
circumstantiality, idiosyncratic speech, or topic shifts on many
occasions OR 1-2 in stances of incoherent phrases.
5 Moderately Severe
Speech difficult to understand due to circumstantiality,
tangentiality, neologisms, blocking, or topic shifts most of the
time OR 3-5 instances of incoherent phrases.
6 Severe
Speech is incomprehensible due to severe impairments most of
the time. Many BPRS items cannot be rated by self-report alone.
7 Extremely Severe
Speech is incomprehensible throughout interview.
16. BLUNTED AFFECT: Restricted range in emotional expressiveness of face,
voice, and gestures. Marked indifference or flatness even when discussing
distressing topics. In the case of euphoric or dysphoric patients, rate Blunted
Affect if a flat quality is also clearly present.
Use the following probes at end of interview to assess emotional responsivity:
Have you heard any good jokes lately? Would you like to hear a joke?
2 Very Mild
Emotional range is slightly subdued or reserved but displays
appropriate facial expressions and tone of voice that are within
normal limits.
3 Mild
Emotional range overall is diminished, subdued, or reserved,
without many spontaneous and appropriate emotional responses.
Voice tone is slightly monotonous.
4 Moderate
Emotional range is noticeably diminished, patient doesn't show
emotion, smile, or react to distressing topics except infrequently.
Voice tone is monotonous or there is noticeable decrease in
spontaneous movements. Displays of emotion or gestures are
usually followed by a return to flattened affect.
5 Moderately Severe
Emotional range very diminished, patient doesn't show emotion,
smile or react to distressing topics except minimally, few
gestures, facial expression does not change very often. Voice
tone is monotonous much of the time.
6 Severe
Very little emotional range or expression. Mechanical in speech
and gestures most of the time. Unchanging facial expression.
Voice tone is monotonous most of the time.
7 Extremely Severe
Virtually no emotional range or expressiveness, stiff movements.
Voice tone is monotonous all of the time.
17. EMOTIONAL WITHDRAWAL: Deficiency in patient's ability to relate emotionally
during interview situation. Use your own feeling as to the presence of an
"invisible barrier" between patient and interviewer. Include withdrawal
apparently due to psychotic processes.
2 Very Mild
Lack of emotional involvement shown by occasional failure to
make reciprocal comments, occasionally appearing preoccupied,
or smiling in a stilted manner, but spontaneously engages the
interviewer most of the time.
3 Mild
Lack of emotional involvement shown by noticeable failure to
make reciprocal comments, appearing preoccupied, or lacking in
warmth, but responds to interviewer when approached.
4 Moderate
Emotional contact not present much of the interview because
subject does not elaborate responses, fails to make eye contact,
doesn't seem to care if interviewer is listening, or may be preoc-
cupied with psychotic material.
5 Moderately Severe
Same as "4" but emotional contact not present most of the
interview.
6 Severe
Actively avoids emotional participation. Frequently unresponsive
or responds with yes/no answers (not solely due to persecutory
delusions). Responds with only minimal affect.
7 Extremely Severe
Consistently avoids emotional participation. Unresponsive or
responds with yes/no answers (not solely due to persecutory
delusions). May leave during interview or just not respond at all.
18. MOTOR RETARDATION: Reduction in energy level evidenced by slowed
movements and speech, reduced body tone, decreased number of
spontaneous body movements. Rate on the basis of observed behavior of the
patient only. Do not rate on the basis of patient's subjective impression of his
own energy level. Rate regardless of the medication effects.
2 Very Mild
Slightly slowed or reduced movements or speech compared to
most people.
3 Mild
Noticeably slowed or reduced movements or speech compared
to most people.
4 Moderate
Large reduction or slowness in movements or speech.
5 Moderately Severe
Seldom moves or speaks spontaneously OR very mechanical or
stiff movements.
6 Severe
Does not move or speak unless prodded or urged.
7 Extremely Severe
Frozen, catatonic.
19 TENSION: Observable physical and motor manifestations of tension,
"nervousness," and agitation. Self-reported experiences of tension should be
rated under the item on anxiety. Do not rate if restlessness is solely akathisia,
but do rate if akathisia is exacerbated by tension.
2 Very Mild
More fidgety than most but within normal range. A few transient
signs of tension, e.g., picking at fingernails, foot wagging,
scratching scalp several times, or finger tapping.
3 Mild
Same as "2," but with more frequent or exaggerated signs of
tension.
4 Moderate
Many and frequent signs of motor tension with one or more signs
some times occurring simultaneously, e.g., wagging one's foot
while wringing hands together. There are times when no signs of
tension are present.
5 Moderately Severe
Many and frequent signs of motor tension with one or more signs
often occurring simultaneously. There are still rare times when no
signs of tension are present.
6 Severe
Same as "5," but signs of tension are continuous.
7 Extremely Severe
Multiple motor manifestations of tension are continuously
present, e.g., continuous pacing and hand wringing.
20. UNCOOPERATIVENESS: Resistance and lack of willingness to cooperate with
the interview. The uncooperativeness might result from suspiciousness. Rate
only uncooperativeness in relation to the interview, not behaviors involving
peers and relatives.
2 Very Mild
Shows nonverbal signs of reluctance, but does not complain or
argue.
3 Mild
Gripes or tries to avoid complying, but goes ahead without argu-
ment.
4 Moderate
Verbally resists but eventually complies after questions are
rephrased or repeated.
5 Moderately Severe
Same as 4, but some information necessary for accurate ratings
is withheld.
6 Severe
Refuses to cooperate with interview, but remains in interview
situation.
7 Extremely Severe
Same as 6, with active efforts to escape the interview.
21. EXCITEMENT: Heightened emotional tone, or increased emotional reactivity to
interviewer or topics being discussed, as evidenced by increased intensity of
facial
expressions, voice tone, expressive gestures or increase in speech quantity
and speed.
2 Very Mild
Subtle and fleeting or questionable increase in emotional
intensity. For example, at times seems keyed-up or overly alert.
3 Mild
Subtle but persistent increase in emotional intensity. For
example, lively use of gestures and variation in voice tone.
4 Moderate
Definite but occasional increase in emotional intensity. For
example, reacts to interviewer or topics that are discussed with
noticeable emotional intensity. Some pressured speech.
5 Moderately Severe
Definite and persistent increase in emotional intensity. For
example reacts to many stimuli, whether relevant or not, with
considerable emotional intensity. Frequent pressured speech.
6 Severe
Marked increase in emotional intensity. For example reacts to
most stimuli with inappropriate emotional intensity. Has difficulty
settling down or staying on task. Often restless, impulsive, or
speech is often pressured.
7 Extremely Severe
Marked and persistent increase in emotional intensity. Reacts to
all stimuli with inappropriate intensity, impulsiveness. Cannot
settle down or stay on task. Very restless and impulsive most of
the time. Constant pressured speech.
22 DISTRACTIBILITY: Degree to which observed sequences of speech and
actions are interrupted by stimuli unrelated to the interview. Distractibility is
rated when the patient shows a change in the focus of attention or a marked
shift in gaze. Patient's attention may be drawn to noise in adjoining room,
books on shelf, interviewer's clothing, etc. Do not rate circumstantiality,
tangentiality, or flight of ideas. Also, do not rate rumination with delusional
material. Rate even if the distracting stimulus cannot be identified.
2 Very Mild
Generally can focus on interviewer's questions with only 1
distraction or inappropriate shift of attention of brief duration.
3 Mild
Patient shifts focus of attention to matters unrelated to the
interview 2-3 times.
4 Moderate
Often responsive to irrelevant stimuli in the room, e.g., averts
gaze from the interviewer.
5 Moderately Severe
Same as above, but now distractibility clearly interferes with the
flow of the interview.
6 Severe
Extremely difficult to conduct interview or pursue a topic due to
preoccupation with irrelevant stimuli.
7 Extremely Severe
Impossible to conduct interview due to preoccupation with
irrelevant stimuli.
23. MOTOR HYPERACTIVITY: Increase in energy level evidenced in more frequent
movement and/or rapid speech. Do not rate if restlessness is due to akathisia.
2 Very Mild
Some restlessness, difficulty sitting still, lively facial
expressions, or somewhat talkative.
3 Mild
Occasionally very restless, definite increase in motor activity,
lively gestures, 1-3 brief instances of pressured speech.
4 Moderate
Very restless, fidgety, excessive facial expressions or
nonproductive and repetitious motor movements. Much
pressured speech, up to one third of the interview.
5 Moderately Severe
Frequently restless, fidgety. Many instances of excessive non-
productive and repetitious motor movements. On the move most
of the time. Frequent pressured speech, difficult to interrupt.
Rises on 1-2 occasions to pace.
6 Severe
Excessive motor activity, restlessness, fidgety, loud tapping,
noisy, etc. throughout most of the interview. Speech can only be
interrupted with much effort. Rises on 3-4 occasions to pace.
7 Extremely Severe
Constant excessive motor activity throughout entire interview,
e.g., constant pacing, constant pressured speech with no pauses,
interviewee can only be interrupted briefly and only small
amounts of relevant information can be obtained.
24. MANNERISMS AND POSTURING: Unusual and bizarre behavior, stylized
movements or acts, or any postures which are clearly uncomfortable or
inappropriate. Exclude obvious manifestations of medication side-effects. Do not
include nervous mannerisms that are not odd or unusual.
2 Very Mild
Eccentric or odd mannerisms or activity that ordinary persons
would have difficulty explaining, e.g., grimacing, picking.
Observed once for a brief period.
3 Mild
Same as "2," but occurring on two occasions of brief duration.
4 Moderate
Mannerisms or posturing, e g., stylized movements or acts,
rocking, nodding, rubbing, or grimacing, observed on several
occasions for brief periods or infrequently but very odd. For
example, uncomfortable posture maintained for 5 seconds more
than twice.
5 Moderately Severe
Same as "4," but occurring often, or several examples of very
odd mannerisms or posturing that are idiosyncratic to the patient.
6 Severe
Frequent stereotyped behavior, assumes and maintains
uncomfortable or inappropriate postures, intense rocking,
smearing, strange rituals, or fetal posturing. Subject can interact
with people and the environment for brief periods despite these
behaviors.
7 Extremely Severe
Same as "6," but subject cannot interact with people or the
environment due to these behaviors.
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