Protocol - Global Psychopathology Rating Scale - Clinical

Brief Psychiatric Rating Scale (BPRS)

Expanded Version (4.0)

Introduction

This section reproduces an interview schedule, symptom definitions, and specific anchor points for rating symptoms on the BPRS. Clinicians intending to use the BPRS should also consult the detailed guidelines for administration contained in the reference belowScale Items and Anchor Points

Rate items 1-10 on the basis of individual’s self-report. Items 11-18 are rated on the basis of observed behaviour 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 individual, 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 individual rates 5 or 6 due to somatic delusions, then you must rate Unusual Thought Content at least 3 or above.

0 Not present

1 Very mild Occasional somatic concerns that tend to be kept to self.

2 Mild Occasional somatic concerns that tend to be voiced to others (e.g., family, doctor).

3 Moderate Frequent expressions of somatic concern or exaggerations of existing ills OR some preoccupation, but no impairment in functioning. Not delusional.

4 Moderately severe Frequent expressions of somatic concern or exaggerations of existing ills OR some preoccupation and moderate impairment of functioning. Not delusional.

5 Severe Preoccupation with somatic complaints with much impairment in functioning OR somatic delusions without acting on them or disclosing to others.

6 Extremely severe Preoccupation with somatic complaints with severe impairment in functioning OR somatic delusions that tend to be acted on or disclosed to others.

"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 individual reports any somatic concerns/delusions, ask the following]:

"How often are you concerned about [use individual’s description]?"

"Have you expressed any of these concerns to others?"

2. Anxiety

Reported apprehension, tension, fear, panic or worry. Rate only the individual’s statements - not observed anxiety which is rated under Tension.

0 Not present

1 Very mild Reports some discomfort due to worry OR infrequent worries that occur more than usual for most normal individuals.

2 Mild Worried frequently but can readily turn attention to other things.

3 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.

4 Moderately severe Frequent, but not daily, periods of anxiety with autonomic accompaniment OR some areas of functioning are disrupted by anxiety or worry.

5 Severe Anxiety with autonomic accompaniment daily but not persisting throughout the day OR many areas of functioning are disrupted by anxiety or constant worry.

6 Extremely severe Anxiety with autonomic accompaniment persisting throughout the day OR most areas of functioning are disrupted by anxiety or constant worry.

"Have you been worried a lot during [mention time frame]? Have you been nervous 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 individual reports anxiety or autonomic accompaniment, ask the following]:

"How much of the time have you been [use individual’s description]?"

"Has it interfered with your ability to perform your usual activities/work?"

3. Depression

Include sadness, unhappiness, anhedonia and preoccupation with depressing topics (can’t attend to TV or conversations due to depression), hopeless, 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.

0 Not present

1 Very mild Occasionally feels sad, unhappy or depressed.

2 Mild Frequently feels sad or unhappy but can readily turn attention to other things.

3 Moderate Frequent periods of feeling very sad, unhappy, moderately depressed, but able to function with extra effort.

4 Moderately severe Frequent, but not daily, periods of deep depression OR some areas of functioning are disrupted by depression.

5 Severe Deeply depressed daily but not persisting throughout the day OR many areas of functioning are disrupted by depression.

6 Extremely severe Deeply depressed daily OR most areas of functioning are disrupted by depression.

"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 individual reports feelings of depression, ask the following]:

"How long do these feelings last?" "Has it interfered with your ability to perform your usual activities?"

4. Guilt

Overconcern or remorse for past behaviour. Rate only individual’s statements, do not infer guilt feelings from depression, anxiety, or neurotic defences. Note: if the individual rates 5 or 6 due to delusions of guilt, then you must rate Unusual Thought Content at least 3 or above, depending on level of preoccupation and impairment.

0 Not present

1 Very mild Concerned about having failed someone, or at something, but not preoccupied. Can shift thoughts to other matters easily.

2 Mild Concerned about having failed someone, or at something, with some preoccupation. Tends to voice guilt to others.

3 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.

4 Moderately severe Preoccupation with guilt, having failed someone or at something, can tum attention to other things, but only with great effort. Not delusional.

5 Severe Delusional guilt OR unreasonable self-reproach very out of proportion to circumstances. Moderate preoccupation present.

6 Extremely severe Delusional guilt OR unreasonable self-reproach grossly out of proportion to circumstances. Individual is very preoccupied with guilt and is likely to disclose to others or act on delusions.

"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 individual reports guilt/remorse/delusions, ask the following]:

"How often have you been thinking about [use individual’s description]?" "Have you disclosed your feelings of guilt to others?"

5. 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 defences, anxiety or somatic complaints. Do not include incidents of appropriate anger or obvious self-defence.

0 Not present

1 Very mild Irritable or grumpy, but not overtly expressed.

2 Mild Argumentative or sarcastic.

3 Moderate Overtly angry on several occasions OR yelled at others excessively.

4 Moderately severe Has threatened, slammed about or thrown things.

5 Severe Has assaulted others but with no harm likely, e.g., slapped or pushed, OR destroyed property, e.g., knocked over furniture, broken windows.

6 Extremely severe Has attacked others with definite possibility of harming them or with actual harm, e.g., assault with hammer or weapon.

"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?"

6. Grandiosity

Exaggerated self-opinion, self-enhancing conviction of special abilities or powers or identity as someone rich or famous. Rate only individual’s statements about himself, not his/her demeanour. Note: if the individual rates 5 or 6 due to grandiose delusions, you must rate Unusual Thought Content at least 3 or above.

0 Not present

1 Very mild Feels great and denies obvious problems, but not unrealistic.

2 Mild Exaggerated self-opinion beyond abilities and training.

3 Moderate Inappropriate boastfulness, e.g., 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.

4 Moderately severe Same as 3 but often self-discloses and acts on these grandiose ideas. May have doubts about the reality of the grandiose ideas. Not delusional.

5 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/she was never employed in these capacities, be Jesus Christ, or the Prime Minister. Individual may not be very preoccupied.

6 Extremely severe Delusional - same as 5 but individual seems very preoccupied and tends to disclose or act on grandiose delusions.

"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 individual reports any grandiose ideas/delusions, ask the following]:

"How often have you been thinking about [use individuals description]? Have you told anyone about what you have been thinking? Have you acted on any of these ideas?"

7. Suspiciousness

Expressed or apparent belief that other persons have acted maliciously or with discriminatory intent. Include persecution by supernatural or other non-human agencies (e.g., the devil). Note: ratings of 2 or above should also be rated under Unusual Thought Content.

0 Not present

1 Very mild Seems on guard. Reluctant to respond to some ’personal’ questions. Reports being overly self-conscious in public.

2 Mild Describes incidents in which others have harmed or wanted to harm him/her that sound plausible. Individual feels as if others are watching, laughing or criticising 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 once per week) with some preoccupation.

4 Moderately severe Same as 3, but incidents occur frequently, such as more than once per week. Individual is moderately preoccupied with ideas of persecution OR individual reports persecutory delusions expressed with much doubt (e.g., partial delusion).

5 Severe Delusional - speaks of Mafia plots, the FBI or others poisoning his/her food, persecution by supernatural forces.

6 Extremely severe Same as 5, but the beliefs are bizarre or more preoccupying. Individual tends to disclose or act on persecutory delusions.

"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 individual reports any persecutory ideas/delusions, ask the following]:

"How often have you been concerned that [use individual’s description]? Have you told anyone about these experiences?"

8. Hallucinations

Reports of perceptual experiences in the absence of relevant external stimuli. When rating degree to which functioning is disrupted by hallucinations, include preoccupation with the content and experience of the hallucinations, as well as functioning disrupted by acting out on the hallucinatory content (e.g., engaging in deviant behaviour due to command hallucinations). Include thoughts aloud (’gedenkenlautwerden’) or pseudohallucinations (e.g., hears a voice inside head) if a voice quality is present.

0 Not present

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

2 Mild While in a clear state of consciousness, hears a voice calling the individual’s 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.

3 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.

4 Moderately severe Experiences daily hallucinations OR some areas of functioning are disrupted by hallucinations.

5 Severe Experiences verbal or visual hallucinations several times a day OR many areas of functioning are disrupted by these hallucinations.

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

"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 odours that others do not smell?"

[If the individual 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?"

9. Unusual thought content

Unusual, odd, strange, or bizarre thought content. Rate the degree of unusualness, not the degree of disorganisation of speech. Delusions are patently absurd, clearly false or bizarre ideas that are expressed with full conviction. Consider the individual to have full conviction if he/she has acted as though the delusional belief was 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 5 or 6 due to delusions, then Unusual Thought Content must be rated 3 or above.

0 Not present

1 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, UFOs, or unrealistic beliefs in one’s own abilities. Not strongly held. Some doubt.

2 Mild Same as 1, 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.

3 Moderate Delusion present but no preoccupation or functional impairment. May be an encapsulated delusion or a firmly endorsed absurd belief about past delusional circumstances.

4 Moderately severe Full delusion(s) present with some preoccupation OR some areas of functioning disrupted by delusional thinking.

5 Severe Full delusion(s) present with much preoccupation OR many areas of functioning are disrupted by delusional thinking.

6 Extremely severe Full delusion(s) present with almost total preoccupation OR most areas of functioning disrupted by delusional thinking.

"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 individual reports any odd ideas/delusions, ask the following]:

"How often do you think about [use individual’s description]?"

"Have you told anyone about these experiences? How do you explain the things that have been happening [specify]?"

10. 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.

0 Not present

1 Very mild Seems muddled or mildly confused 1-2 times during interview. Oriented to person, place and time.

2 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 2 days, or gives wrong division of hospital or community centre.

3 Moderate Frequently confused during interview. Minor inaccuracies in person, place, or time are noted, as in 2 above. In addition, may have difficulty remembering general information, e.g., name of Prime Minister.

4 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 recognising familiar people.

5 Severe Disoriented as to person, place, or time, e.g., cannot give correct month and year. Disoriented in 2 out of 3 spheres.

6 Extremely severe Grossly disoriented as to person, place, or time, e.g., cannot give name or age. Disoriented in all three spheres.

"May I ask you some standard questions we ask everybody?"

"How old are you? What is the date [allow 2 days]"

"What is this place called? What year were you born? Who is the Prime Minister?"

Rate items 11-18 on the basis of observed behaviour and speech.

11. Conceptual disorganisation

Degree to which speech is confused, disconnected, vague or disorganised. Rate tangentiality, circumstantiality, sudden topic shifts, incoherence, derailment, blocking, neologisms, and other speech disorders. Do not rate content of speech.

0 Not present

1 Very mild Peculiar use of words or rambling but speech is comprehensible.

2 Mild Speech a bit hard to understand or make sense of due to tangentiality, circumstantiality, or sudden topic shifts.

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

4 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.

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 severe Speech is incomprehensible throughout interview.

12. 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 individuals, rate Blunted Affect if a flat quality is also clearly present.

0 Not present

1 Very mild Emotional range is slightly subdued or reserved but displays appropriate facial expressions and tone of voice that are within normal limits.

2 Mild Emotional range overall is diminished, subdued or reserved, without many spontaneous and appropriate emotional responses. Voice tone is slightly monotonous.

3 Moderate Emotional range is noticeably diminished, individual 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.

4 Moderately severe Emotional range very diminished, individual 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.

5 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.

6 Extremely severe Virtually no emotional range or expressiveness, stiff movements. Voice tone is monotonous all of the time.

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?"

13. Emotional withdrawal

Deficiency in individual’s ability to relate emotionally during interview situation. Use your own feeling as to the presence of an ’invisible barrier’ between individual and interviewer. Include withdrawal apparently due to psychotic processes.

0 Not present

1 Very mild Lack of emotional involvement shown by occasional failure to make reciprocal comments, appearing preoccupied, or smiling in a stilted manner, but spontaneously engages the interviewer most of the time.

2 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.

3 Moderate Emotional contact not present much of the interview because individual does not elaborate responses, fails to make eye contact, doesn’t seem to care if interviewer is listening, or may be preoccupied with psychotic material.

4 Moderately severe Same as 3 but emotional contact not present most of the interview.

5 Severe Actively avoids emotional participation. Frequently unresponsive or responds with yes/no answers (not solely due to persecutory delusions). Responds with only minimal affect.

6 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.

14. 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 behaviour of the individual only. Do not rate on the basis of individual’s subjective impression of his own energy level. Rate regardless of medication effects.

0 Not present

1 Very mild Slightly slowed or reduced movements or speech compared to most people.

2 Mild Noticeably slowed or reduced movements or speech compared to most people.

3 Moderate Large reduction or slowness in movements or speech.

4 Moderately severe Seldom moves or speaks spontaneously OR very mechanical or stiff movements

5 Severe Does not move or speak unless prodded or urged.

6 Extremely severe Frozen, catatonic.

15. 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.

0 Not present

1 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.

2 Mild Same as 1, but with more frequent or exaggerated signs of tension.

3 Moderate Many and frequent signs of motor tension with one or more signs sometimes occurring simultaneously, e.g., wagging one’s foot while wringing hands together. There are times when no signs of tension are present.

4 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.

5 Severe Same as 4, but signs of tension are continuous.

6 Extremely severe Multiple motor manifestations of tension are continuously present, e.g., continuous pacing and hand wringing.

16. Uncooperativeness

Resistance and lack of willingness to co-operate with the interview. The uncooperativeness might result from suspiciousness. Rate only uncooperativeness in relation to the interview, not behaviours involving peers and relatives.

0 Not present

1 Very mild Shows non-verbal signs of reluctance, but does not complain or argue.

2 Mild Gripes or tries to avoid complying, but goes ahead without argument.

3 Moderate Verbally resists but eventually complies after questions are rephrased or repeated.

4 Moderately severe Same as 3, but some information necessary for accurate ratings is withheld.

5 Severe Refuses to co-operate with interview, but remains in interview situation.

6 Extremely severe Same as 5, with active efforts to escape the interview

17. 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.

0 Not present

1 Very mild Subtle and fleeting or questionable increase in emotional intensity. For example, at times seems keyed-up or overly alert.

2 Mild Subtle but persistent increase in emotional intensity. For example, lively use of gestures and variation in voice tone.

3 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.

4 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.

5 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.

6 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.

18. Mannerisms and posturing

Unusual and bizarre behaviour, stylised 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.

0 Not present

1 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.

2 Mild Same as 1, but occurring on two occasions of brief duration.

3 Moderate Mannerisms or posturing, e.g., stylised 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.

4 Moderately severe Same as 3, but occurring often, or several examples of very odd mannerisms or posturing that are idiosyncratic to the individual.

5 Severe Frequent stereotyped behaviour, assumes and maintains uncomfortable or inappropriate postures, intense rocking, smearing, strange rituals or foetal posturing. Individual can interact with people and the environment for brief periods despite these behaviours.

6 Extremely severe Same as 5, but individual cannot interact with people or the environment due to these behaviours.

Scoring: The BPRS is scored by adding together the scores from the individual items, with higher scores indicating more severe symptoms. Items that are not scored should be left blank (i.e., not scored as "0"). If the total score is being used, missing items can be imputed based on the average item score. If subscales are used, then missing items can be imputed based on the average subscale score and total sum of subscales.

The Brief Psychiatric Rating Scale (BPRS) has been scored on both a 0-6 scale and 1-7 scale. For clinical purposes, the Working Group strongly recommends the scoring on a 0-6 scale as this is much more intuitive.