SCHIZOPHRENIA RATINGS FOR POSITIVE AND NEGATIVE SYMPTOMS

GUIDE FOR SCHIZOPHRENIA RATINGS Brief Negative Symptom Assessment (Items Adopted from NSA and SANS)

Prolonged Time To Response

Observed throughout communication with patient. After asking the patient a question, he or she pauses for inappropriately long period before initiating a response. Delay is considered a pause if it feels as though you are waiting for a response or if you consider repeating the question because it appears the patient has not heard you. He or she may seem "distant" and sometimes the examiner may wonder if he has ever heard the question. Prompting usually indicates that the patient is aware of the questions, but has been having difficulty in developing his thoughts in order to make an appropriate reply. Rate severity on the frequency of these pauses.

= No abnormal pauses before speaking
= Minimal evidence of inappropriate pauses, may be extreme or normal
= Mild. Occasional noticeable pauses before answering questions
= Moderate. Distinct pauses occur frequently (20-40% of responses)
= Marked. Distinct pauses occur most of the time (40-80% of responses)
= Severe. Distinct pauses occur with almost every response (80-100% of responses)

Emotion: Unchanging Facial Expression; Blank, Expressionless Face.

The patient’s face appears, wooden, mechanical, frozen. Facial musculature is generally expressionless and unchanging. The patient does not change expression, or changes less than normally expected, as the emotional content of discourse changes. Because of this, emotions may be difficult to infer. Disregard changes in facial due to abnormal involuntary moments, such as ties and tardive dyskinesia.

= Normal facial expression
= Minimal Reduction in expression, may be extreme or normal
= Mild Facial expressions are observed, but seem reduced or to lag
= Moderate Patient usually maintains a poker face, but shows spontaneous facial expression when discussing topics that interest or humor him or her.
= Marked Facial expressiveness is markedly decreased. Changes in facial expression are observed only after coaxing.
= Severe Patient’s face is always leaden and blank, even after best efforts to stimulate facial expression.

Reduced Social Drive.
This item assesses how much the subject desires to initiate social interactions. Desire may be measured in part by the number of actual or attempted social contact with others. If the patient has frequent contact with someone (e.g., family member) who initiates the contact, does the patient appear to desire the contact (i.e., would he or she initiate contact if necessary). To rate severity, probe the type of social interactions and their frequency.
Assessed by asking patient questions like:
Do you live alone or with someone else?
Do you like to be around people?
Do you spend much time with others?
Do you have difficulty feeling close to them?
Who are your friends? How often do you see them?
Did you see them this past week?
Have you called them on the phone?
When you get together, who decides what to do and where to go?
When you spend time with others, do you ask them to do something with you or do you wait until they ask you do to something?
Is anyone concerned about your happiness or well being?
0 = Normal social drive
1 = Minimal reduction in social drive, may be extreme or normal
2 = Desire for social interactions seems somewhat reduced
3 = Obvious reduction in desire to initiate social contacts, but a
number of social contacts are initiated each week.
4 = Marked reduction in desire to initiate social contact, but a few
contacts are maintained at subject’s initiations (as with family)
5 = No desire to initiate any social interactions
Poor Grooming and Hygiene

Observed during interaction with the patient. The patient displays less attention to grooming and hygiene than normal. The subject presents with poorly groomed hair, disheveled clothing, etc. Do not rate grooming as poor if its simply done in what one might consider poor taste (e.g., wild hairdo or excessive makeup). In addition to observation, one may ask patient about regularity of bathing, brushing teeth, changing clothes, etc.

0 = Normal grooming and hygiene

1 = Minimal Reduction in grooming and hygiene, may be extreme or normal

2 = Mild Clean but untidy, or clothes are mismatched

3 = Moderate Clothes are unkempt or unbuttoned (looks as if patient just got out of bed)

4 = Marked Clothes are dirty or stained, or subject has an odor

5 = Severe Clothes are badly soiled and/or subject has a foul odor

Brief Positive Symptom Assessment (Items Adapted from BPRS)

Suspiciousness: Expressed or apparent belief that other persons have acted maliciously or with discriminatory intent. Includes persecution by super-natural or other non-human agencies (e.g., the devil). Note: Ratings of 2 or above should also be rated under Usual Thought Content.
0 = None
1 = Very Mild Seems on guard. Reluctant to respond to some "personal" questions: Reports being overly self-conscious in public.
2 = Mild Describes incidents where other persons have harmed or wanted to harm him 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.
3 = Moderate Says other persons 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 one time per week) with some preoccupation.
4 = Moderately Same as 4, but incidents occur frequently, such as more than Severe once per week. Patient is moderately preoccupied with ideas of persecution OR patient reports persecutory delusions
expressed with much doubt (e.g. partial delusion).
5 = Severe Delusional. Speaks of Mafia plots, the FBI, or others poisoning his food, persecution by supernatural forces.
6 = Extremely Same as 6,but beliefs are bizarre or more preoccupying. Severe Patient tends to disclose or act on persecutory delusions.
In the last week;
Do you ever feel uncomfortable in public? as people are watching you?
Is anyone trying to harm or interfere with you in any way?
Is anyone going out of their way to give you a hard time, or trying to hurt you?
Have you felt that any people are out to get you?
Do you feel that you are in danger?
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 verbally expressed with full conviction. Consider the patient to have full conviction if she/he has acted as though the delusional belief was true. Ideas of reference/persecution can be differentiated from delusions in that ideas or 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 4 or above.
0 = None
1 = Very Mild Ideas or reference (people stare/laugh at him). Ideas of persecution (people mistreat him). Unusual beliefs in psychic powers, spirits, UFO’s not strongly held, some doubt.
2 = 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 of an unusual experience.
3 = Moderate Delusion present but no preoccupation or functional impairment. May be an encapsulated delusion or firmly endorsed absurd belief about past delusional circumstances.
4 = Moderately Full delusion(s) present with some preoccupation OR some areas of severe functioning disrupted by delusional thinking.
5 = Severe Full delusion(s) present with much preoccupation OR many areas of functioning disrupted by delusional thinking.
6 = Extremely Full delusion(s) present with almost total preoccupation OR most areas of functioning disrupted by delusional thinking.
In the last week:
Have you been receiving any special messages from people or from the way things are arranged around you?
Do you see any reference to yourself on TV or in the newspaper?
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 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?
Hallucinations: Reports of perceptual experiences in the absence of external stimuli. When rating degree to which functioning is disrupted by hallucinations, include preoccupation with the content of the hallucinations, 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).

0 = None

1 = Very Mild While resting or going to sleep, sees visions, smells odors, hears voices,sounds or whispers in the absence of external stimulation, but no impairment of functioning.

2 = Mild While in a clear state of consciousness, hears 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 a week) and with no functional impairment.

3 = Moderate Occasional verbal, visual, gustatory, olfactory, or tactile hallucinations with no functional impairment OR non-verbal auditory hallucinations/visual hallucinations more than infrequently with impairment.

4 = Moderately Experiences daily hallucinations OR some areas of functioning are severely disrupted by these hallucinations.

5 = Severe Experiences verbal or visual hallucinations several times during the day OR many areas of functioning are disrupted.

6 = Extremely Persistent verbal or visual hallucinations throughout the day OR most severe areas of functioning are disrupted by hallucinations.

In the last week:

Do you seem to hear your name being called?

Have you seen any visions or smelled any smells others don’t seem to notice?

(If hears voices) What do the voices say? Did it have a voice quality? (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 to they occur?

4. Conceptual Disorganization: Degree to which speech is confused, disconnected or disorganized. Rate tangentiality, circumstantiality, sudden topic shifts, incoherence, derailment, blocking, neologisms, and other speech disorders. Do not rate content of speech. Consider the whole interview when rating.

0 = None

1 = Very Mild Peculiar use of words, rambling but speech is comprehensible.
2 = Mild Speech a bit hard to understand or make sense due to tangentiality, circumstantiality, or sudden topic shifts.

3 = Moderate Speech difficult to understand due to tangentiality, circumstantiality, or topic shifts on many occasions OR 1-2 instances of incoherent phrases.

4 = Moderately Speech difficult to understand due to circumstantiality, tangentiality, severe neoglisms, blocking or topic shifts most of the time OR 3-5 instances of incoherent phrases.

5 = Severe Speech is incomprehensible due to severe impairment most of the time. Many BPRS items cannot be rated by self report alone.

6 = Extremely Speech is incomprehensible throughout interview.