Rating Scales

NEUROPSYCHIATRY (September 2008) UST Faculty of Medicine and Surgery PSYCHIATRIC RATING SCALES Lecturer: Raymond L. Rosales, M.D. PhD, FPNA, FPPA (with added notes from previous batch) PSYCHIATRIC RATING SCALES • Rating Instruments • Provide a way to quantify aspects of a patient’s psyche, behavior and relationships with individuals and society • Clinicians who do not use rating scales are left only with clinical impressions CHARACTERISTICS OF RATING SCALES 1. can be specific or comprehensive 2. can measure internally experienced variable (eg. mood) 3. can measure externally observable variable (eg. behavior) 4. assess classic items from the mental status examination 5. assessment of adverse effects from psychotherapeutic drugs; social adjustments and psychoanalytic concepts OTHER CHARACTERISTICS 1. time covered 2. level of judgement required 3. method of recording answers a. dichotomous variable (eg. true or false, present or absent) b. continuos variable (eg. severity, frequency) PSYCHIATRIC RATING SCALES A. Rating scales used for Schizophrenia of Psychosis B. Rating scales used for Mood disorders C. Rating scales used for Anxiety disorders D. Others: 1. Child/adolescent patients 2. Adverse effects of drugs 3. Quality of life 4. Dissociative disorders A. Rating Scales in Schizophrenia of Psychosis 1. Brief Psychiatric Rating Scale (BPRS) 2. Positive and negative symptom scale (PANSS) 3. Schedule for Affective Disorders and Schizophrenia (SADS) 4. Scale for the Assessment of Negative Symptoms (SANS) 5. Scale for Assessment of Positive Symptoms (SAPS) 6. Scale for the Assessment of Thought, Language and Communication (TLC) 7. Thought Disorder Index (TDI) 8. Quality of Life Scale (QLS) 9. Chestnut Lodge Prognostic Scale for Chronic Schizophrenia

Symptoms Somatic concern Anxiety Depression Suicidality Guilt Hostility Elated Mood Grandiosity Suspiciousness Hallucinations Unusual thought content Bizarre behaviour Self-neglect Disorientation Conceptual disorganisation Blunted affect Emotional withdrawal Motor retardation Tension Uncooperativeness Excitement Distractibility Motor hyperactivity Mannerisms and posturing

7 Point Scale 0 - Not Assessed 1 - Not Present 2 - Very Mild 3 - Mild 4 - Moderate 5 - Moderately Severe 6 - Severe 7 - Extremely severe

A.2. PANSS RATING MANUAL(Positive and negative symptom scale) Background • developed and standardized for typological and dimensional assessment of schizophrenic phenomena • 33 items, 7 point rating • Evaluates positive, negative and other symptom dimensions on the basis of a formal semi-structured clinical interview and other informational sources. • Domains Positive Scale General Psychopathology Negative Scale Supplemental Aggression Risk Composite • Adaptation of the BPRS and the Psychopathology rating schedule • Positive – 7 items • Negative – 7 items • Composite – difference between Positive and Negative symptoms • General Psychopathology - 16

B. Rating Scales in Affective Disorders 1. Young Mania Rating Scale – for Bipolar Disorder 2. Hamilton Rating Scale for Depression (HAM-D) 3. Montgomery-Asberg Depression Rating Scale (MADRS) 4. Becks Depression Inventory 5. Standard Assessment of Depressive Disorder (SADD) 6. Zung Self-rating Scale for Depression 7. Caroll Rating Scale for Depression 8. Raskin Depression Rating Scale 9. Inventory to Diagnose Depression 10. Mania State Rating Scale C. Rating Scales used for Anxiety disorders 1. Hamilton A rating scale for Anxiety (HAM – A) 2. Acute Panic Inventory 3. Covi Anxiety Scale 4. Anxiety States Inventory 5. Yale Brown Obsessive Compulsive Scale 6. Brief Outpatient Psychopathology Scale 7. Physician's Questionnaire 8. Fear Questionnaire 9. Mobility Inventory For Agoraphobia 10. Social Avoidance and Distress Scale 11. Leyton Obsessional Inventory 12. Fear Thermometer 13. Impact of Events Scale Rating Scales for Functioning 1. Social Occupational Functioning Assessment Scale (SOFAS) 2. Global Assessment of Relational Functioning (GARF) A.1. Brief Psychiatric Rating Scale (BPRS) • Administered by: Psychiatrists, psychologists or other trained rater • Time to complete: 15-30 minutes • 18-item scale measuring positive symptoms, general psychopathology and affective symptoms. • When rating BPRS, it is important to allow unstructured sections in the clinical interview such that conceptual disorganization in the patient's thought and speech and unusual thought content can be observed. • Each item is rated on a seven-point scale (1=not present to 7=extremely severe)

Instructions: For each item below (P1, P2, etc.) enter the code that best describes the patient’s psychopathology. POSITIVE SCALE P1 DELUSIONS: Beliefs which are unfounded, unrealistic, and idiosyncratic. Basis for rating: thought content expressed in the interview and its influence on social relations and behavior. 1 = Absent – Definition does not apply. 2 = Minimal – Questionable pathology; may be at the upper extreme of normal limits 3 = Mild – Presence of one or two delusions which are vague, uncrystallized and not tenaciously held. Delusions do not interfere with thinking, social relations or behavior. 4 = Moderate – Presence of either a kaleidoscopic array of poorly formed, unstable delusions or a few well-formed delusions that occasionally interfere with thinking, social relations or behavior 5 = Moderate Severe – Presence of numerous well-formed delusions that are tenaciously held and occasionally interfere with thinking, social relations or behavior. 6 = Severe – Presence of stable set of delusions which are crystallized, possibly systematized, tenaciously held, and clearly interfere with thinking, social relations and behavior

7 = Extreme – Presence of stable set of delusions which are either highly systematized or very numerous and which dominate major facets of the patient’s life. This frequently results in inappropriate and irresponsible action, which may even jeopardize the safety of the patient or others. P2 CONCEPTUAL DISORGANIZATION: Disorganized process of thinking characterized by the disruption of goal-directed sequencing, (e.g., circumstantiality, tangentiality, loose associations, non sequiturs, gross illogicality, or thought block). Basis for rating: cognitive-verbal processes observed during the course of the interview. 1 = Absent – Definition does not apply. 2 = Minimal – Questionable pathology; may be at the the upper extreme of normal limits. 3 = Mild – Thinking is circumstantial, tangential, or paralogical. There is some difficulty in directing thoughts toward a goal, and some loosening of associations may be evidenced under pressure. 4 = Moderate – Able to focus thoughts when communications are brief and structured, but becomes loose or irrelevant when dealing with more complex communications or when under minimal pressure. 5 = Moderate Severe – Generally has difficulty in organizing thoughts, as evidence by frequent irrelevancies, disconnectedness, or loosening of associations when not under pressure. 6 = Severe – Thinking is seriously derailed and internally inconsistent, resulting in gross irrelevancies and disruption of thought processes, which occur almost constantly. 7 = Extreme – Thoughts are disrupted to the point where the patient is incoherent. There is marked loosening of associations, which results in total failure of communication, (e.g. “word salad”) or mutism. B.1. The Young Mania Rating Scale (YMRS) • Appropriate for: Assessment/severity of mania (most appropriate for bipolar 1 disorder) • Administered by: Trained clinician • Time to complete: 15-30 minutes • an 11-item instrument used to assess the severity of mania in patients with a diagnosis of bipolar disorder. • The 11 items are: Elevated Mood, Increased Motor Activity Energy, Sexual Interest, Sleep, Irritability, Speech (Rate and Amount), Language - Thought Disorder, Content, Disruptive Aggressive Behaviour, Appearance and Insight. YMRS features operationally-defined anchor points and the normal expected score is >=20. Ratings are based on patient self-reporting, combined with clinician observation (accorded greater score). YMRS 1: Elevated Mood 0 = Absent. 1 = Mildly or possibly increased on questioning. 2 = Definite subjective elevation: Optimistic, self confident; cheerful; appropriate to content. 3 = Elevated; inappropriate to content; humorous. 4 = Euphoric; inappropriate laughter; singing. YMRS 2: Increased Motor Activity 0 = Absent. 1 = Subjectively increased. 2 = Animated; gestures increased. 3 = Excessive energy; hyperactive at times; restless (can be calmed). 4 = Motor excitement; continuous (cannot be calmed). YMRS 3: Sexual Interest 0 = Normal; not increased. 1 = Mildly or possibly increased. 2 = Definite subjective increase on questioning. 3 = Spontaneous sexual content; elaborates on sexual matters; hypersexual by self report. 4 = Overt sexual acts (toward patients, staff, or interviewer). YMRS 4: Sleep 0 = Normal; not decreased. 1 = Sleeping less than normal amount by up to one hour. 2 = Sleeping less than normal amount by more than one hour. 3 = Reports decreased need for sleep. 4 = Denies need for sleep. YMRS 5: Irritability 0 = Absent. 2 = Subjectively increased. 4 = Irritable at times during the interview; recent episodes of anger or annoyance on ward (or usual environment). 6 = Frequently irritable during interview; short, curt throughout. 8 = Hostile, uncooperative, interview impossible. YMRS 6: Speech 0 = No increase. 2 = Feels talkative. 4 = Increased rate or amount at times, verbose at times. 6 = Push; consistently increased rate and amount; difficult to interrupt. 8 = Pressured; uninterruptible, continuous speech (during the interview).

YMRS 7: Language/Thought Disorder 0 = Absent. 1 = Circumstantial; mild distractibility; quick thoughts. 2 = Distractible: loses goal of thoughts; changes topic frequently; racing thoughts. 3 = Flight of ideas; tangentiality; difficult to follow; rhyming; echolalia. 4 = Incoherent; communication impossible. YMRS 8: Content 0 = Normal. 2 = Questionable plans, new interests. 4 = Special project(s), Hyper-religious. 6 = Grandiose or paranoid ideas (inappropriate); ideas of reference. 8 = Delusions, hallucinations. YMRS 9: Disruptive-Aggressive Behavior 0 = Absent, cooperative. 2 = Sarcastic; loud at times, guarded. 4 = Demanding; threats on ward (or usual environment). 6 = Threatens interviewer; shouting (during interview); interview difficult. 8 = Assaultive; destructive, interview impossible. YMRS 10: Appearance 0 = Appropriate dress and grooming. 1 = Minimally unkempt. 2 = Poorly groomed and moderately disheveled; Overdressed. 3 = Disheveled; partly clothed; garish make-up. 4 = Completely unkempt; decorated; bizarre garb. YMRS 11: Insight 0 = Present; admits illness, agrees with need for treatment. 1 = Possibly ill. 2 = Admits behavior change, but denies illness. 3 = Admits possible change in behavior, but denies illness. 4 = Denies any behavior change. B.2. HAMILTON RATING SCALE FOR DEPRESSION (HAM-D) • Administered by: Physician or trained raters • Time to complete: 30 minutes • a 17-21 item observer-rated scale to assess presence and severity of depressive states where anxiety-related symptoms are prevalent and no other depressive symptoms • 9 items are scored 0-4, the further 8 are scored 0-2, as these represent variables which do not lend themselves to quantitative rating (0=absent; 1=doubtful or slight; 2=mild; 3=moderate; 4=severe. 0=absent; 1=doubtful or slight; 2=clearly present). Items 18-21 are not regarded as measuring the intensity of depression and are commonly omitted. • A score of 11 is generally regarded as indicative of a diagnosis of depression. • HAM-D contains items that assess: • Somatic symptoms • Insomnia • Working capacity and interest • Mood • Guilt • Psychomotor retardation • Agitation • Anxiety • Insight Instructions: For each item select the “cue” which best describes the patient. 1: Depressed Mood (Sadness, hopeless, helpless, worthless) 0 = Absent 1 = These feelings states indicated only on questioning 2 = These feeling states spontaneously reported verbally 3 = Communicates feeling states nonverbally—ie, through facial expression, posture, voice, and tendency to weep 4 = Patient reports VIRTUALLY ONLY these feeling states in his spontaneous verbal and nonverbal communication 2: Feelings of Guilt 0 = Absent 1 = Self-reproach, feels he has let people down 2 = Ideas of guilt or rumination over past errors or sinful deeds 3 = Present illness is a punishment. Delusions of guilt 4 = Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations 3: Suicide 0 = Absent 1 = Feels life is not worth living 2 = Wishes he were dead or any thoughts of possible death to self 3 = Suicide ideas or gesture 4 = Attempts at suicide (any serious attempt rates 4) 4: Insomnia early 0 = No difficulty falling asleep 1 = Complains of occasional difficulty falling asleep – ie, more than ¼ hour 2 = Complains of nightly difficulty falling asleep faye_umali

5: Insomnia middle 0 = No difficulty 1 = Patient complains of being restless and disturbed during the night 2 = Waking during the night—any getting out of bed rates 2 (except for purpose of voiding) B.3. Montgomery-Asberg Depression Rating Scale • 10-item scale to measure the core symptoms and cognitive features of clinical depression • Originally a subscale of Comprehensive Psychopathological Rating Scale, or CPRS (Asberg et al. 1978) • Symptoms are rated on a scale from 0-6 • Anchor points at ratings of 0, 2, 4, and 6 MADRS 1: Apparent Sadness Representing despondency, gloom and despair (more than just transient low spirits) reflected in speech, facial expressions, and posture. Rate by depth and inability to brighten up. Rate by observation 0 1 2 3 4 5 6

No sadness

1 2 3 4

5 6

Looks dispirited Appears sad and unhappy most of the time

Occasional sadness in keeping with the circumstances. Sad or low; brightens up without difficulty. Pervasive feelings of sadness or gloominess. The mood is still influenced by external circumstances. Continuous or unvarying sadness.

3 4

5 6

3 4

5 6

5 6

No appetite. Food is tasteless. Needs persuasion to eat at all.

No difficulties concentrating. Occasional difficulties in collecting one’s thoughts. Difficulties in concentrating and sustaining thought which reduces the ability to read or hold a conversation. Unable to read or converse without great difficulty.

MADRS 7: Lassitude Rate the ability to start activities or tasks Determine if tasks/activities were actually started Probe to determine if normal daily living activities were affected • If affected, determine if outside assistance was required (such as friends or family members) Representing a difficulty getting started or slowness initiating and performing everyday activities. 0 1 2 3 4 5 6

Some feelings of edginess or ill-defined discomfort.

Hardly any difficulty getting started. sluggishness.

No

Difficulties starting activities. Difficulties in starting simple routines which are carried out with effort. Complete lassitude. Unable to do anything without help.

Continuous feelings of inner tension or intermittent panic, which can be mastered with some difficulty. Unrelenting dread Overwhelming panic.

or

anguish.

MADRS 8: Inability to Feel Probe for subject’s normal level of activities in which he/she participates • Determine the level of disinterest (if appropriate) in participating. • Ask the subject why the level has changed. Determine if subject is able to connect with others, such as family or friends Representing the subjective experience of reduced interest in the surroundings or activities that normally give pleasure. The ability to react with adequate emotion to circumstances or people is reduced. 0

3 4

Slightly reduced appetite.

Placid. Only fleeting inner tension.

MADRS 4: Reduced Sleep Probe for and rate any sleep related issues, including restless sleep and any trouble falling asleep. Distinguish if symptom is normal (e.g., if an infant is in the household, broken sleep could be considered normal) Representing the experience of reduced duration or depth of sleep compared with the subject’s normal pattern when well. Rate past week. 0 1 2

Normal or increased appetite.

MADRS 6: Concentration Difficulties Rate only difficulty with concentration, regardless of circumstances If patient reports no need to concentrate (e.g., on vacation, not working), probe on ability to concentrate on other normal activities (reading paper, conversations, etc) Use the script, ask all questions Representing difficulties in collecting one’s thoughts mounting to incapacitating lack of concentration. Rate according to the intensity, frequency, and degree of incapacity produced.

Looks miserable all the time. Extremely despondent.

MADRS 3: Inner Tension Representing feelings of ill defined discomfort, edginess, inner turmoil, mental tension mounting to either panic, dread, or anguish. Rate according to the intensity, frequency, duration, and the extent of reassurance called for. 0 1 2

0 1 2 3 4 5 6

0 1 2

MADRS 2: Reported Sadness Representing reports of depressed mood, regardless of whether it is reflected in appearance or not. Rate according to intensity, duration and the extent to which the mood is reported to be influenced by events. 0

Representing the feeling of loss of appetite compared with when well. Rate by desire for food or the need to force oneself to eat.

Sleeps as usual.

1 2 3 4 5 6

Slight difficulty dropping off to sleep or slightly reduced, light or fitful sleep. Sleep reduced or broken by at least 2 hours. Less than 2 or 3 hours of sleep.

MADRS 5: Reduced Appetite Frequently underrated item: This item measures both appetite and interest in eating. Raters must ask about both symptoms Do not assume a change in weight reflects an increase/decrease in appetite or interest in eating Use all scripted probing questions, even if patient reports appetite is normal

Normal interest in surroundings and other people. Reduced ability to enjoy usual interests. Loss of interest in surroundings. Loss of feelings for friends and acquaintances. The experience of being emotionally paralyzed, inability to feel anger, grief or pleasure and a complete or even painful failure to feel for close relatives and friends

MADRS 9: Pessimistic Thoughts Determine the occurrence and severity of pessimistic thoughts/lack of optimism Determine if subject feels as if they have let others down or have done something wrong • Determine if feelings are justified/rational • Probe for subjective awareness of guilt Representing thoughts of guilt, inferiority, self-reproach, sinfulness, remorse, and ruin. 0 1 2

No pessimistic thoughts. Fluctuating ideas of failure, self-reproach or self-deprecation. faye_umali

3 4

5 6

Persistent self-accusations, or definite but still rational ideas of guilt or sin, increasingly pessimistic about the future. Delusions of ruin, remorse, or unredeemable sin. Self–accusations which are absurd or unshakable.

MADRS 10: Suicidal Thoughts It is important to evaluate the frequency or severity of suicidal thoughts Determine if the subject has made any plans for suicide For safety, subjects that have current plans for suicide should be treated appropriately Representing the feeling that life is not worth living, that a natural death would be welcome, suicidal thoughts, and preparation for suicide. Suicidal attempts should not, in themselves, influence the rating. 0 1 2 3 4

5 6

Enjoys life or takes it as it comes. Weary of life. thoughts.

Only fleeting suicidal

Probably better off dead. Suicidal thoughts are common and suicide is considered as a possible solution, but without specific plans or intention. Explicit plans for suicide when there is an opportunity. Active preparations for suicide.

Disease Severity MADRS • No Symptoms • Mild • Moderate • Severe

0 – 12 13 – 21 22 – 29 30 – 60

C.1. HAMILTON ANXIETY RATING SCALE (HAM-A) Instructions: This checklist is to assist the physician or psychiatrist in evaluating each patient as to his degree of anxiety and patholigical condition. Please fill in the appropriate rating: NONE = 0 MILD = 1 MODERATE = 2 SEVERE = 3 SEVERE, GROSSLY DISABLING = 4 ITEM Anxious Worries, anticipation of the worst, fearful anticipation, irritability Tension Feelings of tension, fatigability, startle response, moved to tears easily , trembling, feelings of restlessness, inability to relax Fears Of dark, of strangers, of being left alone, of animals, of traffic, of crowds Insomnia Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night-terrors Intellectual (cognitive) Difficulty in concentration, poor memory Depressed Mood Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing Somatic (muscular) Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone Somatic (sensory) Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, picking sensation Cardiovascular Symptoms Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat Respiratory Symptoms Pressure or constriction in chest, choking feelings, sighing, dyspnea Gastrointestinal Symptoms Difficulty in swallowing, wind, abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation Genitourinary Symptoms Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence Autonomic Symptoms Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair Behavior at Interview Fidgeting, restlessness or acing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, belching, brisk tendon jerks, dilated pupils, exophthalmos

RATING

faye_umali