WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1
Schedules for Clinical Assessment in Neuropsychiatry Version 2.1.
GOSSA!" #ifferential definitions of SCAN items and commentary on the SCAN manual World Health Or$ani%ation Assessment& Classification and 'pidemiolo$y Geneva 1((( WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 2 CON)'N)S ACKNOWLEDGMENTS
)he development of SCAN *as funded +y N,H& WHO& the ield )rial Centers& and the ,nstitutes employin$ individual contri+utors. World Health Or$ani%ation TB Üstün N,H D Regier Regier (NIMH), J Blaine Blaine (NIDA), (NIDA), B Grant, and and L Towle (NIAAA). (NIAAA). Glossary 'ditors A Bertelsen, Bertelsen, T Brg!a, Brg!a, and A" Tien. Tien. Ac/no*led$ments to the *or/ of centers and individuals *ho helped in the development of particular components of SCAN *ill +e found in the SCAN te0t. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 CON)'N)S CONTENTS OF SCAN GLOSSARY PRESENT STATE EXAMINATION PART ONE General Introdution #evelopment and +asic principles Setion ! SCAN face sheet and sociodemo$raphic items 13 Setion " 4e$innin$ the intervie* 15
# Somatoform and dissociative symptoms 27 $ Worryin$& tension& etc. 6 % 8anic& an0iety and pho+ias 36 & O+sessional symptoms 2 ' #epressed mood and ideation ( )hin/in$& concentration& ener$y& interests 75 ) 4odily functions 52 * 'atin$ disorders 57 "! '0pansive mood and ideation (1 "" 9se of alcohol (
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 6 CON)'N)S Setion "# 9se of psychoactive su+stances other than alcohol 1:3 Setion "$ ,nterference and attri+utions for 8art One 12 Stress and ad;ustment disorder 125 Setion "% Screen for items in 8art )*o 11 PRESENT STATE EXAMINATION PARTTWO Setion "& an$ua$e pro+lems at e0amination 12 Setion "' 8erceptual disorders other than hallucinations 1
!atin$ Scale ,, 16 Setion "( Hallucinations 161 Setion ") '0periences of thou$ht disorder and replacement of *ill 13: Setion "* #elusions 135 Setion #! urther information for classification of 8art )*o symptoms 17: ,nterferences and attri+utions for part t*o 17: Ne$ative syndrome and items 171 Setion #" Co$nitive impairment and decline 17 Setion ##
!atin$ Scale ,> 21 CLINICAL ,ISTORY SC,ED+LE Setion #( Clinical History Schedule 2
!eferences 23
A--endi./ Selected disorders from other chapters of ,C#-1: 25
ist of SCAN )rainin$ Centers 26( WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 G'N'!A ,N)!O#9C),ON General introdution to t0e SCAN 121te3 DE4ELOPMENT AND 5ASIC PRINCIPLES
)he SCAN system ?Schedules for Clinical Assessment in Neuropsychiatry@ is a set of instruments and manuals aimed at assessin$& measurin$ and classifyin$ the psychopatholo$y and +ehavior associated ass ociated *ith the ma;or psychiatric disorders of adult life. )he SCAN te0t has components the tenth edition of the 8resent State '0amination ?8S'1:@& the ,tem Group Chec/list ?,GC@ and the Clinical History Schedule ?CHS@. 8S'1: itself has t*o parts. 8art , covers somatoform& dissociative& an0iety& depressive and +ipolar disorders& and pro+lems associated *ith eatin$& alcohol and other su+stance use. )here is also a screen for 8art ,, conditions. 8art ,, covers psychotic and co$nitive disorders and o+served a+normalities of speech& affect and +ehavior. )he SCAN system contains t*o other essential elements the Glossary of differential definitions and CA)'GO& a set of computer pro$rams for processin$ SCAN data and providin$ output. #ata from the schedules can +e entered into CA)'GO in a variety of *ays on the SCAN Schedules themselves& on SCAN Codin$ Sheets& and into a computer pro$ram. Output from CA)'GO is presented as a series of options& includin$ a ran$e of profiles of symptom and ,GC scores& an ,nde0 of #efinition& ,C#-1: and #S< cate$ories& a predia$nostic profile of cate$ories& and a list of items rated present. )here are t*o manuals one is a )rainin$ 8ac/ for SCAN trainin$ centers& the other a !eference
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 G'N'!A ,N)!O#9C),ON 7 )he principles underlyin$ the 8S' have chan$ed very little durin$ these developments +ut they have $radually +een applied to a +roader ran$e of disorders& have come to incorporate more and more aspects of the clinical history and& throu$h the use of an increasin$ly comple0 technolo$y& have +een preserved *ithout loss of the +asic clinical +ottom-up approach and user friendliness. fr iendliness. An understandin$ of the history is therefore therefor e a useful +asis for an appreciation of SCAN. )he SCAN !eference
8reparations for a tenth edition of the 8S' *ere started in 1(5:& in anticipation of the tenth edition of the ,C#. )he ma;or emphasis of correspondents *as on +roadenin$ the content& +oth +y returnin$ to the lar$er item-pool of 8S'7 and 8S'5& and +y addin$ ne* sections to cover somatoform& dissociative and eatin$ disorders& alcohol and dru$ misuse& and co$nitive impairments. A second su$$estion *as that an e0tra ratin$ point *as needed to e0tend the :-1-2 scales of severity used for most 8S'( items& allo*in$ a mild or su+-clinical level to +e used& particularly in population surveys. A third& very o+vious& re=uirement *as for a +etter system for ratin$ episodes of disorder& addin$ other
information relevant to the history and to the causes of disorder& and processin$ all the information +y means of one set of computer pro$rams. )he pu+lication and *idespread use of #S<-,,, and later its revised version& #S<-,,,-! ?A8A& 1(57@& meant that the WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 5 G'N'!A ,N)!O#9C),ON latter and& perhaps more usefully& #S<-,> ?A8A& 1((6@& re=uired clinical supplements. >ersions 2 and 2.1 of SCAN incorporates chan$es +rou$ht a+out +y #S<-,>. )his *or/ has +een ta/en for*ard +y a )as/ orce on 8sychiatric Assessment ,nstruments& esta+lished *ithin the frame*or/ of a ;oint WHOEN,H pro;ect aimed at improvin$ the accuracy and relia+ility of measurement and classification of psychiatric disorders ?Fa+lens/y& et al & 1(5@. Apart from SCAN& t*o other instruments have +een sponsored +y the )as/ orce. One is the Composite ,nternational #ia$nostic ,ntervie* ?C,#, !o+ins et al& 1(55@ *hich is desi$ned for use +y lay intervie*ers in population surveys. )he other is the ,nternational 8ersonality #isorder '0amination ?,8#'@. An early version of SCAN *as used in a study of the service needs of lon$ term attenders at day hospitals and day centers in Cam+er*ell& south-east ondon ?4ru$ha et al& 1(55@. )his provided a severe test of the historical capacities of SCAN& since the attenders had +een in contact *ith services for an avera$e of 17 years and nearly half did not have conditions that could +e dia$nosed from a present state intervie* alone. )he results *ere satisfactory in this respect. ield trials of the third ?e+ruary 1(55@ draft of SCAN *ere underta/en under the auspices of WHO& after /ey participants from 2: centers& in 16 countries& had +een trained in ondon. )he te0t *as translated into all the local lan$ua$es& +ased on the principle that it *as more important to translate the concepts than the *ords. ,ndependent +ac/translation of the /ey items *as used as a chec/. '0tra trials *ere underta/en of sections that *ere not sufficiently tested in the main series +ecause of lac/ of num+ers. )hese included the eatin$& co$nitive& and alcohol and su+stance use sections. )he results& and detailed reports from the Centers& indicate that feasi+ility and relia+ility *ere fully up to the standards reported for the earlier editions. )he practical comments of participatin$ intervie*ers *ere invalua+le durin$ the innumera+le te0tual revisions of the past five years. As part of the preparation of SCAN >ersions 2 and 2.1& incorporatin$ chan$es necessitated +y #S<-,>& further field trials have +een carried out providin$ data on the cross cultural compara+ility of items on use of alcohol and dru$s +eyond prescription. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 G'N'!A ,N)!O#9C),ON ( T,E P+RPOSE OF T,E SCAN SYSTEM
)he purpose of the SCAN system is to provide comprehensive& accurate and technically specifia+le means of descri+in$ and classifyin$ psychiatric phenomena& in order to ma/e comparisons.
)rainin$ in SCAN techni=ues provides a common clinical lan$ua$e in *hich to compare and contrast the e0periences and +ehavior of patients& to consider the usa$e of different clinical schools in relation to a common reference system& to compare epidemiolo$ical and pu+lic health data more precisely& and to ma/e the results of scientific research readily availa+le for replication +et*een centers. CLINICAL CROSS6EXAMINATION
)he function of the Glossary is to support the process of clinical cross-e0amination& *hich is the central method of o+tainin$ information a+out the respondents su+;ective e0periences. )rainin$ in the differential definitions provides the e0aminer *ith a set of item concepts& *hich are matched a$ainst the respondents descriptions. Only *hen the description matches the concept does the e0aminer ma/e the ratin$. )his process helps to eliminate syndromal& dia$nostic and other +iases& misunderstandin$s& and yea-sayin$. Considera+le trainin$ and e0perience is needed +efore the pro+e system in the SCAN te0t can +e used fle0i+ly enou$h in close con;unction *ith the Glossary to ensure that the ratin$s most accurately fit the phenomena. A full description of the techni=ue is $iven in the !eference +oo/ and the )rainin$ 8ac/. CO4ERAGE OF SCAN
Sections 1-23 of SCAN ?8S'1:@ covers the symptoms and si$ns of disorders in su+chapters :-3 of ,C#-1: and their e=uivalents in #S<. Some Sections have optional Chec/lists attached& *hich cover items related to disorders that re=uire specific time relationships& for e0ample to psychosocial trauma& as in the stress and ad;ustment disorders. Other Chec/lists allo* a more e0tended list of items to +e rated than is provided in the main te0t for e0ample the e0tra list of somatoform sy mptoms& #7!)!6 #7"$&. Optional Chec/list items& *hich include items not already e0istin$ else*here& are not defined in the Glossary. SCAN REFERENCE MAN+AL
)he reference manual is pu+lished in +oo/ form ?Win$ FB& Sartorius N& and stn )4& 1((@. ,t contains an account of the history and development of SCAN from +e$innin$s in the second half of the 1(3:s. Chapters are devoted to the aims& the principles and the techni=ues of SCAN& the results of international field trials& and the varieties of computer output. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 1: G'N'!A ,N)!O#9C),ON SCAN TRAINING PACK
)he Glossary is one element in the SCAN )rainin$ 8ac/& *hich also contains materials for SCAN )rainin$ Centers& trainers and trainees. )he pac/ provides a comprehensive introduction to the SCAN te0t& the Glossary& and scorin$ +oo/lets& *ith instructions for their use& materials for SCAN )rainin$ Courses& and recommendations concernin$ the duties of )rainin$ Centers. 9pon completion of field testin$& ne* computer pro$rams under development *ill +e included in the )rainin$ 8ac/ ?see +elo*@.
)he use of these materials is descri+ed in a document o+taina+le from the #ivision of & has also +een incorporated *here appropriate.
)he Glossary contains differential definitions of aspects of e0perience or +ehavior that are common amon$ people referred for a specialist psychiatric opinion. 'ach aspect is allocated an item in the SCAN te0t& *ith a uni=ue item-num+er and item-name. )he correspondin$ definitions are listed in the Glossary in numerical order. ,tems represent su+;ectively descri+ed symptoms or si$ns o+served in +ehavior. Symptoms and si$ns are sometimes referred to as phenomena. ?9sers of SCAN >ersion 1 should note the e0tensive renum+erin$ of items in >ersion 2. No renum+erin$ occurred from SCAN 2 to SCAN 2.1@. )hese terms mi$ht su$$est that the items are lin/ed to theories of cause or patholo$y& and therefore that SCAN items mi$ht represent symptoms and si$ns of diseases. Such hypotheses are not part of the structure of SCAN. A central principle is that phenomena are rated on their o*n merit& irrespective of any theory a+out the *ay they cluster& their causes or their psychosocial or +iolo$ical nature. ,t is only in this *ay that a
comprehensive clinical picture can +e o+tained& on *hich classifyin$ andEor dimensional rules of various /inds can operate. No particular set of rules should +e allo*ed to influence decisions as to *hether any symptom or si$n is present. )erms li/e neurotic& affective& psychotic and or$anic are used descriptively& in the same spirit. )here are items *here the e0aminer can ma/e an attri+ution a+out patholo$y or aetiolo$y or relationship to other phenomena& +ut these are clinical ;ud$ements re=uired +y rule-+ased dia$nostic systems such as ,C#-1: and #S<-,>& not specifications +y the SCAN system. As an option& a scale to code attri+utions of etiolo$y is included in >ersion 2.1 of the SCAN. Codes can +e entered in +o0es *ith dashed lines +elo* the standard episode ratin$ +o0es. )he ratin$ of in Scale , in >ersion 1 of the SCAN has +een removed& in order to emphasi%e ratin$ of phenomenolo$y irrespective of etiolo$y. )he terminolo$y of symptoms and si$ns is used for convenience only. or research purposes& ne* ratin$ +o0es have +een added to code etiolo$y attri+utions if desired. )his approach is not fully tested for relia+ility and validity and is optional. ,n >ersion 1 )raits *ere distin$uished from symptoms on the +asis that they have persisted since adolescence and there has +een no e0acer+ation that could +e re$arded as an onset. ,n >ersion 2.1& the dates of 8'!,O#S of symptoms can +e dated separately in each Section& if necessary. )rait ratin$s are not made. )he term disorder is used as in ,C#-1:& Dto imply the e0istence of a clinically reco$ni%a+le set of symptoms or +ehaviorsD. >arious sets of rules for reco$ni%in$ such disorders are incorporated into computer pro$rams& not in the SCAN te0t. )he main sets of rules are those in the #ia$nostic Criteria for !esearch of ,C#-1: and in the #S< manuals. Any nosolo$ical system *ith sufficiently operationali%ed rules can +e accommodated& perhaps *ith an item supplement. )hus& the SCAN te0t is +ottom-up& in the sense that it provides a means of $atherin$ data accordin$ to the Glossary definitions& independently of the type of top-do*n WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 12 G'N'!A ,N)!O#9C),ON classification applied. )hese data can +e used to provide profiles and scores of many different /inds. TEXT CON4ENTIONS IN SCAN
,n the printed SCAN te0t a standard format is used for almost all items. 'ach has its o*n +loc/ of te0t& *hich can consist of up to five su+-+loc/s. )he full format is illustrated +y item $7!!"& Worryin$. ?1@ )he first line contains the item num+er& the item name in italic& and t*o open +o0es ?one for each of t*o possi+le episodes@ for the entry of ratin$s. )here are t*o dashed line +o0es +elo* the standard +o0es. )hese are for the optional ratin$ of attri+ution. ?2@ )he second component& also in italic& contains the main pro+e?s@ for the item. ,n this case& there is only one =uestion Have you *orried a $reat deal durin$ I8'!,O#JK& +ut there can +e several.
?@ )he third component contains optional pro+es in italic& preceded +y a hyphen. ,n this case& five e0tra pro+es are su$$ested. ?6@ )he fourth component follo*s after a +lan/ line. )his is a +rief reminder& of the item-definition& sometimes also a note a+out the ratin$ scale. ?3@ )he fifth component& the ratin$ scale& is also preceded +y a +lan/ line. )he components are also distin$uished +y different indentations from the left mar$in. )hese conventions are follo*ed throu$hout the te0t of SCAN& +ut not all items re=uire all five components. !arely& pro+e =uestions have the initial +lac/ mar/er +ut no item num+er& name or +o0. )his happens a+ove the cut-off point in Section 1 and in a fe* other places. )he mar/er is there to dra* attention to the need to as/ the pro+e. A55RE4IATIONS
Commonly used a++reviations include ! !espondent. S Section. 8S 8resent State. 8' 8resent 'pisode. 4 ifetime 4efore. !' !epresentative 'pisode. 8" 8ast "ear. ,GC ,tem Group Chec/list. CHS Clinical History Schedule. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 G'N'!A ,N)!O#9C),ON 1 ,C#-1:-#C! ,nternational Classification of #iseases& 1:th edition& #ia$nostic Criteria for !esearch. #S<-,,,-! #ia$nostic and Statistical #ia$nostic and Statistical
)hese indicate a s/ip to the ne0t Section. )hey are sho*n +y the *ords C9) O in the left mar$in& follo*ed +y 89 and instructions& *ith a continuous line +elo*. SKIP POINTS
)hese indicate movement to another item in the same section. )hey are sho*n +y SB,8 in the left mar$in& follo*ed +y 89 and instructions& +ut no line. GENERAL POINTS A5O+T RATING SCALES I6I4 AND OT,ER SCALES
)here are four main ratin$ scales& placed at the +e$innin$ of the sections in *hich they are used. !atin$ Scale , is placed immediately +efore Section and is the main scale used in Sections to . !atin$ Scale ,, is placed immediately +efore Section 1 and is the main scale used in
Sections 1 to 1(. !atin$ Scale ,,, is placed at the +e$innin$ of Section 22& and is the main scale for ratin$ Sections 22 to 26. !atin$ Scale ,> is placed at the +e$innin$ of Section 2& the ,tem Group Chec/list. )he optional etiolo$y attri+ution scale is placed follo*in$ Scale , and Scale ,,& and can +e used at any item *ith the optional etiolo$y +o0es. )hese +o0es are located +elo* the episode ratin$ +o0es and have dashed instead of solid lines. )he relia+ility or validity of etiolo$ical attri+utions at the item have not +een systematically studied. urther investi$ation may +e desira+le in specific pro;ects. ,nterested users should contact their trainin$ center for further information on the availa+ility of data entry and classification al$orithms usin$ this scale. ra-0i ite31 !7!!" 6 !7!#! Fae S0eet
)he ace Sheet provides important identifyin$ data and other information essential to the proper runnin$ of the computer pro$rams. ,t should invaria+ly +e completed carefully and chec/ed +efore the data are entered. When usin$ the laptop version& this chec/in$ process is particularly important. )he choice of episodes& and the use of the non-routine option& are descri+ed in Section 1 +elo*. )he use of the Clinical History Schedule ?item !7!"&@ in research studies is recommended +ecause of its value for international co-mor+idity and descriptive studies. )he World Health Or$ani%ation intends to compile a li+rary of data from SCAN series. At the least it is useful to enter an independent clinical dia$nosis at items #(7!(" 6 #(7!)). !7!#" 6 !7!#* Soiode3o>ra-0i ite31
)hese items& li/e those in the CHS& are optional +ut recommended. )hey are used to provide descriptive statistical profiles from series of SCAN cases. )his output can +e o+tained at once if the laptop version of SCAN is used. 5e>innin> t0e inter?ie; INTROD+CTION
)he Section starts *ith the instruction that the intervie*er should +e *ell informed +efore startin$ the intervie* and +e prepared for a num+er of possi+le contin$encies. Apart from studies of $eneral population samples it *ill usually +e possi+le to anticipate
some of the li/ely pro+lems in conductin$ the intervie* accordin$ to the routine recommendation. )hese include the follo*in$ difficulties Se?ere lan>ua>e -roniti?e i3-air3ent
Complete Section 13 for lan$ua$e disorders& Section 21?+ehavioral and history items for co$nitive disorder@& Sections 22-23 ?more $eneral +ehavior& affect and speech items@& and Clinical History Schedule. Se?ere
4e$in *ith those Sections that are most relevant to !. Beep the conversation $oin$ as far as possi+le and o+serve speech& affect and +ehavior ?Sections 22-23@. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 1 SOC,O#'
ad;ustment disorders& use information from case records or informant to chec/ the details of the event& and complete the full SCAN as soon as possi+le after*ards. Pro3inent di11oiati?e 123-to31 Complete items #7"!# 6 #7""( ?dissociative symptoms@& o+tain information from
informants and case records& and complete the full SCAN. Dru> or alo0ol u1e
,f the main pro+lem& Section 11 or 12 may +e ta/en first& +ut the *hole of SCAN should +e completed and attri+utions of cause and effect rated. Eatin> di1order1
,f the main pro+lem& +e$in *ith Sections 5-(& then return to Section 1 and complete SCAN. In >eneral
4e$in *ith Section 1& +ut then ta/e Sections the respondent most *ants to discuss or that are clearly predominant in the clinical picture. )his *ill provide a more complete intervie* on the important topics. ,f the intervie* is li/ely to +e incomplete& try to ta/e sections *ith hi$hly relevant items first. DATING EPISODES AND PERIODS
)en +road types of symptoms and si$ns are rated in SCAN. ,t has already +een emphasi%ed that the terminolo$y used is purely descriptive. Symptoms associated *ith alcohol and dru$ use& and eatin$ pro+lems& form a $roup of ha+it disorders that are often accompanied ?*hether +y cause& effect or chance@ +y neurotic& affective or psychotic symptoms. Stress& somatoform and dissociative symptoms can +e associated *ith any of
the fore$oin$. Co$nitive impairment can similarly produce or complicate any of the other types. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 AC' SH'') AN# SOC,O#'niti?e i3-air3ent and deline
!ated in 8S'1: Section 21. Only the 8resent State ?8S@ is rated. Alo0ol and dru> u1e -ro
!ated in 8S'1: Sections 11 and 12. )*o periods can +e rated 8ast "ear& or year +efore /ey date ?8"@& and ifetime 4efore ?4@ or period from onset to 8". So3atofor3 and di11oiati?e 123-to31
!ated in 8S'1: Section 2. !ated for 8ast 2 "ears ?8"@ for somatoform disorders. Eatin> -ro
!ated in 8S'1: Section (. !ated for 8ast "ear ?8"@ and representative ?previous@ 'pisode ?!'@. P120oti= affeti?e and neuroti 123-to31
)hese types of symptom can co-present *ith any of the four types listed a+ove. )hey are rated in 8S'1: Sections -1:& 1-2:& and 22-23. )*o periods can +e rated 8resent State ?8S@ OR 8resent 'pisode ?8'@ and either !epresentative ?previous@ 'pisode ?!'@ OR ifetime 4efore ?4@. General instructions for ratin$ them are provided in Section 1. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 15 4'G,NNNG )H' ,N)'!>,'W " 5e>innin> t0e inter?ie; INTROD+CTION AND O4ER4IEW
,f none of the special contin$encies descri+ed earlier determine other*ise& and if the Special 'pisode ist is not +ein$ used& it is recommended that the e0aminer routinely +e$in the intervie* *ith Section 1. )his is +ecause neurotic& affective and psychotic symptoms are li/ely to accompany any of the other types& and it is sensi+le to $et the overall pattern of the clinical history clear& in colla+oration *ith the respondent& +efore decidin$ *here +est to start. Note the instruction that the e0aminer should +e as fully informed as possi+le +efore +e$innin$ the intervie*. 8oints in the case records or made +y informants can +e used *ith careful discretion as e0tra prompts. "7!!" 6 "7!!' Preli3inar2 ue1tion1 on t0e our1e
)he *ay this preliminary part of the intervie* is conducted is at the discretion of the e0aminer& usin$ all the information at disposal to o+tain a $eneral overvie* of the history of clinically si$nificant neurotic& affective or psychotic symptoms. )he overall descriptive
definition is symptoms included in Sections to 1:& 13 to 1(& and 22 to 23 of 8S'1:. "7!!( 6 "7!#& General -oint1 a and datin> e-i1ode1
Once the presence of clinically si$nificant periods of any of these symptom-types is decided& the intervie* is focused on a$reein$& *ith the respondent& the appro0imate dates of the periods that *ill +e discussed. )his must +e a colla+orative effort& particularly if& say& t*o episodes out of a comple0 clinical history are to +e rated. 4oth the intervie*er and respondent have to +e a+le to orient themselves correctly in order to rate them appropriately. )his revie* should culminate +y assessin$ the dates of first onset of the main types of pro+lem. ,t is usually most convenient to enter these as a$es of first onset. No pro+es are su$$ested to cover the ha+it or co$nitive or Section 2 symptom-types& +ut if they can +e included in a natural *ay into the flo* of the intervie* at this sta$e& it is *ise to cover them. Ho*ever& there is no need to date the time periods of these pro+lems in this Section. An episode is a period of time throu$hout *hich clinically si$nificant symptoms persist *ith no symptom-free intervals lastin$ 2 months or more. Such an episode could last a fe* days or many years. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 4'G,NN,NG )H' ,N)'!>,'W 1( )hree ratin$ periods are reco$ni%ed +y the CA)'GO computer pro$ram 8S& !' and 4. Althou$h 8S primarily refers to the clinical state of the su+;ect for the past month& 8S is also used to refer to a representative part of a much lon$er episode& *hich has not yet clearly remitted ?the present episode& 8'@. ,t is important to /eep in mind these t*o su+tly different meanin$s and uses of the 8S. !' is a previous episode characteri%ed chiefly +y one of the three types of symptom. 4 is a period containin$ more than one episode. All three can +e rated +y usin$ either 8S'1: or ,GC. #ates are determined +y clinical ;ud$ement. #etailed pro+es are not laid do*n& since the proceedin$s must +e conducted accordin$ to the uni=ue clinical history of each respondent and in the interest of creatin$ a relationship +et*een e0aminer and respondent that *ill provide a solid +asis of trust on *hich to +uild the intervie*. )he information needed is comple0& private& confidential and difficult for the respondent to descri+e in terms that are sufficiently =uantifia+le to ma/e it compara+le *ith the descriptions provided +y other people. )he o+;ect of the SCAN intervie* is to create the conditions in *hich this transfer of communication can nevertheless ta/e place. PRESENT STATE BPS and PRESENT EPISODE BPE
8S represents the clinical state present durin$ the month +efore the date of e0amination. As *as the case *ith 8S'(& the term month should +e understood as notional or appro0imate it could +e e0tended up to *ee/s or so& dependin$ on the intervie*ers clinical ;ud$ement. )he episode need not have +e$un durin$ the month. ,n other *ords& the 8S also may +e part of a much lon$er present episode ?8'@& *ith onset years earlier. )hus& the 8S either fully constitutes& or is the most recent part of& a 8'. )he
onset of the 8' must +e preceded +y at least 2 months *ithout clinically si$nificant symptoms. )he date of onset of the episode in days and months is entered at item "7!!(. ,f the 8resent State is part of a continuous episode that has lasted lon$er than a month& *ith many characteristic symptoms still present +ut *ith a pea/ more than the notional month a$o& it is permissi+le to e0tend the period a little in order to accommodate the most characteristic symptoms *ithin the 8S. )he most common occasion is li/ely to +e *hen a patient has +een admitted to hospital and has recovered to some e0tent +efore the intervie*. ,n lon$er chronic illness& if the 8' e0tends +ac/ in time considera+ly further and some si$nificant symptoms manifest then are no lon$er present& these could +e rated usin$ !' or 4. )he num+er of days covered +y the 8S is recorded at item "7!!)& so that it is clear ho* compara+le the results are *ith those of others in the series. When SCAN is used to structure the intervie* *ith people *ho do not have si$nificant clinical symptoms at e0amination& the 8S' 8art One should +e completed for the previous month& consistin$ of all the a+ove-cut-off items and the Screen ?Chec/-8S'@. )his occurs most fre=uently ?a@ ,n a population or $eneral practice survey& *here many respondents *ill not +e in episode as defined a+ove ?+@ ,n clinical situations *here acute episodes are infre=uent& for e0ample in follo* up clinics& lon$-stay *ards& day centers or hostels WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 2: 4'G,NNNG )H' ,N)'!>,'W ?c@ When the disorder is only minor or ta/es the form of ne$ative symptoms& and the most characteristic clinical pictures have occurred in previous episodes. ?d@ When the !espondent has lon$-term and clinically si$nificant pro+lems on e0amination that have lasted perhaps for years& +ut cannot +e split up into episodes +ecause fluctuations are not sufficiently mar/ed. '0amples mi$ht include very lon$-term dysthymic or somatoform disorders& and personality disorders *ith occasional minor symptoms. ,n such cases& the *hole course of the condition constitutes one episode as defined in SCAN. 4ecause si$nificant symptoms are present durin$ the month +efore e0amination& no symptom-free period lastin$ 2L months is included& and there are no si$nificant symptoms durin$ the 2 months +efore onset& 8S is the appropriate period to rate. ,f it lasts throu$hout the *hole clinical course& from early adolescence& it is a form of lifetime ever. Ho*ever& it does not need a special desi$nation since 8S represents the *hole course. ,f the time of symptom onset varies accordin$ to the type of symptom& a separate date of onset can +e recorded in each Section of 8S'-1:. 8S can +e rated in the ,tem Group Chec/list& from case records or an informant& if the !espondent is un*illin$ or una+le to supply information. PRE4IO+S EPISODE
A previous episode is any period of clinically si$nificant symptoms occurrin$ *ith a
2 month or $reater interval *ithout si$nificant symptoms +efore the episode& and similarly separated from any other episode +y at least a 2 month clear interval. One e0ception to this mi$ht +e in the not uncommon clinical situation *ith lon$ term& continuous chronic illness *here there is no 2 month period *ithout si$nificant symptoms. When important symptoms that are not present no* e0isted too far +ac/ in time to reasona+ly +e included in the 8S& they can +e rated usin$ the previous episode option. )*o /inds are conventionally distin$uished !' and 4. REPRESENTATI4E EPISODE BRE
,f there has +een one particular episode +efore 8S *hich& alone or in com+ination *ith 8S& provides an ade=uate covera$e of the si$nificant clinical symptomatolo$y for dia$nostic purposes& it is dated and desi$nated a !epresentative 'pisode ?!'@. ,t should +e chosen +y consultation *ith !. A notional month at the pea/ of the disord er *ill +e most informative. !' *ill usually +e used in association *ith 8S. ,t can also +e rated usin$ the ,tem Group Chec/list& if the !espondent is una+le or un*illin$ to provide details and if $ood records andEor a $ood informant are availa+le. Once !' is chosen& the dates are entered at item "7!!*. T0ree o33on u1e1 for RE are/
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 4'G,NN,NG )H' ,N)'!>,'W 21 ?a@ ,f the !espondent is in episode ?8S@ at the time of intervie*& and !' contains symptoms of similar type +ut *ith a more characteristic symptom profile& it *ill often +e useful to rate +oth episodes 8S L !'. ?+@ ,f 8S and one particular !' contain different clinical pictures ?for e0ample& manic and depressive symptoms@& the t*o sets of ratin$s *ill +e processed separately. ?c@ ,f ! is not in an episode at the time of intervie* ?as confirmed +y the Chec/-8S@& !' is the chief source of information a+out a sin$le past episode. LIFETIME 5EFORE BL5
4 is dated from the first onset of disorder to the +e$innin$ of the period covered in 8S. 8SL4 therefore constitute another form of lifetime ever. 4 is mainly used *hen there have +een several previous episodes& *hether discrete or mer$in$ into each other& that contain different types of symptom - e.$. psychotic& affective and neurotic - *ith the possi+ility of several dia$noses. ,t may then +e necessary ?dependin$ on the nature of the 8resent State@ to choose different pea/ periods for t*o episodes *ith different types of symptom +ut to rate them as thou$h they *ere su+-episodes of one e0tended episode. )he dates of episodes rated in 4 are rated under the relevant symptom type at items "7!"" to "7!"%. )he routine CA)'GO pro$ram processes the information as part of one episode +ut& if su+-episodes are specified +y symptom type and date& the relevant parts of the data can +e identified for each separately. ,t should +e emphasi%ed that identifyin$ the symptom type of an episode does not compromise the independence of the classification since the
CA)'GO pro$ram does not ta/e this information into account *hen cate$ori%in$. ,t is& in any case& symptomatic& not dia$nostic. Symptom scores and ,tem Group profiles& ho*ever& can only +e provided for the *hole of 4. ,t is also possi+le to record the date of previous 'pisodes separately in each Section. "7!"& 6 "7!") A>e of fir1t on1et of 123-to3 t2-e1 "7!"* ualit2 of re3i11ion1
)his item should +e rated usin$ all the information at disposal. ,f the respondent has had more than one episode of depression ?Section @ or of elation ?Section 1:@& the datin$ of previous episodes should +e recorded in those Sections ?'7!$) 6 '7!%$ and "!7!## 6 "!7!#(@ ta/in$ account of the ratin$ of item "7!"*. "7!#! 6 "7!#& S-eial e-i1ode li1t BO-tion
!atin$ 4 does not provide a full 8S' profile for each type of disorder rated durin$ the overall period. or pro;ects that re=uire this de$ree of detail& an episode list should WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 22 4'G,NNNG )H' ,N)'!>,'W +e completed instead of 8S and 4. )his allo*s the specification of up to si0 dated episodes ?or periods@& each of *hich can +e rated usin$ the full 8S'1:& or ,GC& or some of either. 'ach episode is processed separately and the 8ro;ect #irector *ould +e responsi+le for puttin$ the results to$ether. or some very detailed research pro;ects it may +e useful to complete +oth the routine and the non-routine options for each mem+er of the series. "7!#' 6 "7!$( Mediation
)his list of items is included in order to record the use of various /inds of medication at the time of intervie* and the effect this has had on symptoms ?item "7!$'@ and on the intervie* itself ?item "7!$(@. "7!$) 6 "7!%% P120o1oial treat3ent1
)his list performs a similar purpose to the previous list ?i.e. medication@. "7!%& 6 "7!&$ Ot0er a1-et1 of linial 0i1tor2
)hese items provide an additional vie* of the clinical history that can +e used in con;unction *ith co-mor+idity studies to compare symptom& ,tem Group or cate$ory profiles. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 !A),NG SCA'S ,N 8A!) ON' 2 Ratin> 1ale1 in Part One GENERAL POINTS
)he main ratin$ scale in Sections - is Scale ,. )he ratin$ points are specified in the SCAN te0t& at the +e$innin$ of Section & and ela+orated on the ne0t pa$e of the Glossary. Ho*ever& many items ?particularly in other sections of 8art One@ have their o*n individual ratin$ scales& *hich are specified *ithin their item +loc/s. ,t should +e noted that all symptom items can +e rated at points :& 3& 5& and (& usin$ the definitions $iven in
Scale ,& *hether or not these points are specified in the te0t. or ma/in$ etiolo$ical attri+utions& many items have +o0es *ith dashed line +elo* the episode ratin$ +o0es. )hese are optional ratin$s that are not re=uired& +ut *hich may +e useful for research purposes& and in certain clinical situations. )he purpose is to separate the ratin$s of phenomenolo$y from any rata+le etiolo$ical factors for e0ample 8ar/insons disease& or the effects of alcohol or other dru$s. )he etiolo$y scale should +e used to code any attri+ution of etiolo$y. RATING SE4ERITY
)he severity of a symptom can +e assessed in terms of duration& persistence& de$ree of interference *ith other mental functions& distress& impairment of everyday activities& effect on other people& and contact *ith services of various /inds. ,n SCAN& the approach is to measure clinical severity +y the duration and fre=uency of the symptom and the de$ree of interference *ith mental functions ?intensity@. Social and occupational performance& other peoples reactions& and help-see/in$ +ehavior ?all of *hich can +e influenced +y many other factors@& are assessed separately. Some*here +et*een the t*o lies the respondents o*n reaction& +ut this may +e stoical or distressed accordin$ to temperament and circumstances& and is therefore also re$arded as addin$ a de$ree of am+i$uity to the ratin$. #istress is only mentioned in items *hich use criteria from a rule-+ased system that re=uires it to +e present. )hese points hold $ood for ratin$s throu$hout SCAN and& in particular& for the four main !atin$ Scales. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 26 !A),NG SCA'S ,N 8A!) ON' RATING SCALE I
1. )his is a positive ratin$ of presence& +ut presence of such a minor de$ree that it is not appropriate for use in classification. i/e ?:@& it does not mean not /no*n or uncertain. !atin$s of ?1@ count in scores& *hich in turn influence the level allocated on the ,nde0 of #efinition. 2. )his ratin$ means that the item is present at a level sufficient to use in classification. or this purpose it is e=uivalent to & +ut it contri+utes less to scores. ,n $eneral& it is used *hen symptoms are of moderate severity durin$ most of the period +ein$ assessed. . A ratin$ of ?@ is similar to ?2@ e0cept that the symptom is present in severe form for most of the period under revie*. 3. )he presence of psychotic symptoms can ma/e the ratin$ of 8art One items very difficult& +ecause of pro+lems in interpretin$ the meanin$ of *hat ! says& or +ecause the symptoms ?for e0ample& an0iety or a pho+ia a+out leavin$ ones house@ may themselves +e +ased in psychotic e0periences. )he ratin$ should only +e made *hen there is $enuine dou+t a+out the nature of the symptom or the +alance is in favor of the symptom +ein$ psychotic. 5. ,f& after an ade=uate e0amination& the intervie*er is still not sure *hether a symptom is present ?rated 1-@ or a+sent ?rated :@& the ratin$ is ?5@. )his is the only WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 !A),NG SCA'S ,N 8A!) ON' 23 circumstance in *hich ?5@ is used. ,t should not +e used to indicate a mild form of the symptom. (. )his ratin$ is only used if the information needed to rate an item is incomplete in some respect& for e0ample +ecause of lan$ua$e or co$nitive disorder& or lac/ of cooperation& or +ecause the intervie*er for$ot to pro+e sufficiently deeply. ,t is distin$uished from ?5@ +ecause the e0amination *as not& for *hatever reason& carried out ade=uately. ,n the SCAN te0t& an instruction to use Scale , simply means that it is not necessary to point out any individual ratin$ characteristics for that item. Any point on Scale , can +e selected& accordin$ to clinical ;ud$ement. or duration ratin$s& duration less than one *ee/Emonth should +e rated 1. A ratin$ of : thus means that the phenomenon has +een totally a+sent. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 2 !A),NG SCA'S ,N 8A!) ON' OPTIONAL RATINGS OF ITEM6SPECIFIC ATTRI5+TIONS
SCAN users and raters *ith =ualification and practice e0perience in medicine and clinical pharmacolo$y& studyin$ patients follo*in$ appropriate& e0tensive& physical and la+oratory investi$ation may *ish to rate ;ud$ements of definite attri+utions of cause at an item level. or each period first rate the item usin$ the appropriate SCAN ratin$ scale ?,,>@& in the standard scorin$ +o0es& and then the nature of the attri+ution in the dashed +o0es +elo* the standard +o0es& usin$ us in$ the scale provided. 9p to t*o periods can +e
rated. Note that the conventional use of :& 3& 5& and ( does not apply and these scores have specific meanin$. )he items should +e rated on the +asis of certainty& presence& and severity in the standard ratin$ +o0es +efore recordin$ in the associated optional attri+ution ratin$ +o0es. )he follo*in$ optional ratin$s should only +e made +y investi$ators plannin$ to study their validity. )he relia+ility of ma/in$ these ratin$s should +e esta+lished. )hey represent a more detailed *ay of recordin$ ratin$s of attri+ution of or$anic cause throu$hout the SCAN. )here is also an opportunity to ma/e a trait ratin$ of individual items ?i.e. a ratin$ of D7D on ratin$ SCA' , of SCAN version 1@. 9sers should contact their trainin$ center for information a+out their use in SCAN al$orithms. ATTRI5+TIONAL RATING SCALE BO-tional
9se the A))!,49),ONA ratin$ scale to rate nature of influence on symptom presence or severity at the item level. )he ratin$ of : is the only ne$ative ratin$& and can +e used if there is clear evidence that treatment has resulted in a reduced ratin$. !atin$s 1 - 5 represent attri+utions of etiolo$ic effect& increasin$ the li/elihood of an item +ein$ rated or its severity +ein$ increased. )hese attri+utions must only +e made for symptoms or items that have +een positively rated& and should +e entered into the dashed +o0es +elo* the standard episode ratin$ +o0es. )he ratin$ of ( is reserved for indicatin$ a trait characteristic. ,f no effect or trait is ;ud$ed to +e present leave the dashed +o0 +lan/. : ,tem ratin$ reduced +y effects of treatment. 1 Alcohol. 2 Other psychoactive su+stance. 'ffects of somatic psychiatric treatments ?electroconvulsive therapy& antidepressant medication& neuroleptics& etc@. 6 Bno*n primary intracranial process ?Al%heimers disease& Huntin$tons disease& 8ar/insons disease& tumor& stro/e& etc.@. 3 Non-psychiatric medication& to0ins. Other medication or condition 1 ?specify at Section 1 andEor Section 2:@. 7 Other medication or condition 2 ?specify at Section 1 andEor Section 2:@. 5 Other medication or condition ?specify at Section 1 andEor Section 2:@. ( )rait. 'ssentially lifelon$ characteristic of !. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O
)he somatoform symptoms considered in this Section re=uire an assurance that no ade=uate physical e0planation has +een found. )his does not imply that a full e0planation in physical terms is impossi+le& since /no*led$e is not that far advanced. )he same caveat applies to all the symptoms and +ehavioral si$ns that are rated in SCAN. )he somatoform su+section +e$ins *ith items ?#7!!" 6 #7!!*@ concerned *ith $eneral physical health and *ell-+ein$. )his provides enou$h information to esta+lish *hether
somatoform or dissociative symptoms ?#7!"! 6 #7!)" and #7"!# 6 #7""(@ are present. ,f the e0aminer considers that there is& or pro+a+ly is& a physical e0planation for all the clinically si$nificant symptoms descri+ed +y !& s/ip out of the Section alto$ether. )he cut-off point is al*ays passed if there is any dou+t. )he period rated is usually the past year& for somatoform symptoms past 2 years& +ut provision is made for ratin$ a$e of onset on set of the first and present episodes. ,f , f an earlier episode is needed for research purposes& the Special 'pisodes ist ?see items !7!"' and "7!#! 6 "7!#&@ can +e used. ,t is particularly important to use all the information at disposal *hen ratin$ Section 2 items& includin$ informants& case records and the results of clinical investi$ations.
)his item is concerned *ith the !espondents o*n vie* of his or her o*n physical health status i.e. not only *ith the presence or a+sence of disease or disa+ility +ut also *ith $eneral physical *ell-+ein$. !espondents *ill use their o*n terms to descri+e health status. )he ratin$ should reflect this personal assessment rather than intervie*ers interpretation of it. A ratin$ of 1 must +e +ased on a positive statement of physical *ell+ein$. !easona+ly *ell ?rated 2@ corresponds to all ri$ht not positive& not ne$ative. A ratin$ of ?fair@ implies less than avera$e fitness. Such a statement should +e elucidated to inform su+se=uent =uestionin$. ,t may& for e0ample& indicate physical disorder& somatoform or dissociative or affective disorder& or a lifelon$ tendency ?trait@ to ta/e a some*hat $loomy vie* of thin$s. )hese =uestions are raised later in the intervie*. Any statement implyin$ a seriously poor state of health& is rated 6. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 25 SO' S"<8)Ot0 of unfitne11 ,f item #7!!" is rated or 6& specify the len$th of time in years and months that the
unfitness has +een present. #7!!$ C0an>e in ;ei>0t= -a1t 2ear
Wei$ht loss or $ain may +e associated *ith many mental and physical disorders.
)his item is purely descriptive a useful pro+e to orient su+se=uent =uestionin$. )*o /ilo$rams ?3 l+s in the 9B@ *ithin a +rief period ?up to si0 *ee/s@ is ta/en as the ar+itrary threshold +et*een ma;or and minor chan$e.
)hese items refer to medical pro+lems of a physical nature includin$ illnesses& in;uries and disa+ilities. )a/e into account all the information availa+le includin$ the results of recent investi$ations and e0aminations. ,t *ill sometimes +e possi+le to accept the dia$nosis that ! $ives& *hen +ac/ed +y a convincin$ description& +ut al*ays use 5 if there is dou+t. Any medically dia$nosed condition should +e coded in #7!!& and #7!!'& accordin$ to ,C#-1:. ,f no si$nificant illness or disa+ility is present leave #7!!& and #7!!' +lan/. An entry should only +e made if #7!!% is coded 2 not includin$ any indefinite or medically une0plained disorder. or instance stomach ache *ithout $ood evidence of $astric disease& should not +e entered simply +ecause ! states& for e0ample& D, thin/ , have a $astric ulcerD. A ratin$ of 1 does not mean that there is no physical disease& only that the information has not esta+lished one and further en=uiry is necessary. #7!!( Pre3en1trual 123-to31= -a1t 2ear
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O
#istin$uish dysmenorrhea ?painful menses@ *here the symptoms are associated only *ith the duration of the menses. 8remenstrual a$$ravation or e0acer+ation of any e0istin$ mental disorder such as an0iety disorders or depressive disorders should not count since
they do not remit after the onset of the menses. Ho*ever& if ! e0periences characteristic symptoms *hich are mar/edly different from those of the co-e0istin$ disorder& the item may +e rated positively. #7!!) Li3itation1 on -021ial ati?itie1= -a1t 2ear
!estriction of daily life activities +ecause of medical pro+lems rated present in items #7!!" 6 #7!!(. 8lease note that any limitation or deficit caused +y a medical disorder mi$ht *ell +e overcome +y the development of compensatin$ s/ills or the use of medical aids or prostheses. )he intervie*er should rate the respondents assessment of any limitation. #7!!* Sati1fation ;it0 are= -a1t 2ear
)his item is part of the screen for somatoform and dissociative disorders. ,f the respondent is satisfied *ith the investi$ations carried out and the e0planations offered& and if it is clear that any physical symptoms present can +e e0plained +y physical disease or disa+ility& s/ip to Section . ,t may sometimes +e useful to ta/e other sections first& e.$. Section 6 if there is mar/ed an0iety or Section -5 if there is mar/ed depression& returnin$ to Section 2 if a somatoform condition re=uires further e0ploration. C+T6OFF POINT
Al*ays continue +eyond the cut-off point if there is any dou+t as to *hether physical health pro+lems have a clearly physical ori$in. 4e$in the further e0ploration *ith a $eneral pro+e& then as/ a set of =uestions concernin$ !s contacts *ith e0pert practitioners. ,n countries *here e0pert opinion is difficult to o+tain the follo*in$ ratin$s WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 : SO' S"<8)O
)he 8S rated in this section should include the past t*o years +ut could +e lon$er. #7!"! 6 #7!)" Li1t of >rou-ed 1o3atofor3 123-to31
)his list of items is rou$hly $rouped +y physiolo$ical system& includin$ pain& $astrointestinal& cardiovascular& uro$enital& neurolo$ical& s/in or $lands& and autonomic divisions. )here may +e overlap +et*een items. )o rate a symptom as present& esta+lish that it is not fully e0plained +y any detecta+le or$anic patholo$y or demonstrated cause and that it has $iven rise to multiple consultations *ith doctors ?local healers& etc.@& selfmedication andEor chan$e of life-style. 9se the list of pro+es in the SCAN te0t& in addition to information from case records and /no*led$ea+le informants& to esta+lish the e0tent to *hich the pro+lems have +een investi$ated. 4ecause each symptom can +e descri+ed in terms that are hi$hly culture specific& the list is not e0haustive. )here are sufficient items to cover contin$encies. A clinical decision has to +e made on the +asis of e0pert local /no*led$e as to *hich item
represents the complaint most closely. or research purposes& it is important to record the terms used +y respondents to descri+e their pro+lems. #ocumentation of these terms *ill $enerate a data +ase that can +e used for further development of items *ith research and clinical applica+ility. 'ach item in the list& if affirmed& can +e assessed usin$ the listed pro+es concernin$ contacts *ith e0perts. )his *ill form a conte0t in *hich the rest of the Section 2 intervie* *ill +e carried out. )he items allo* ratin$s of $roups of similar symptoms. )he usual 8S' rule if in dou+t rate do*n should not +e applied to somatoform symptoms themselves. !espondents should +e encoura$ed to +e forthcomin$ a+out their complaints. Ho*ever& this does not alter the rule that these complaints must not +e caused +y detecta+le physical patholo$y. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O1 #7!"& Pain1 in t0e oint1 #7!"' C0e1t -ain1
Aches& pains& pressure& +urnin$& stin$in$ feelin$s in the chest or over the heart. #7!"( A
A+dominal pain& cramps due to *ind& +o*el spasms& constipation. ,ntolerance to several /inds of food should +e rated at #7!$&. !ate +ad taste in mouth at #7!$# and loose +o*els at #7!#*. #7!") Pain1 durin> 3en1truation #7!"* Pain1 durin> 1e.ual interour1e #7!#! Pain1 durin> urination
8ain or +urnin$ sensation durin$ urination. #7!#" Pain1 in retu3 #7!## Pain1 in ot0er or>an1 or -art1 of t0e
)his item covers symptoms not included in the precedin$ items. #7!#$ Pain 3o?in> fro3 one -lae to anot0er
Aches and pains not included in previous items. ,t covers aches or pains in any other site of the +ody. e.$. pain +ehind the nec/& pain in rectum etc. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 2 SO' S"<8)O
#7!#% Nau1ea
eelin$ of dis$ust& revulsion& sensation that precedes vomitin$. #7!#& 4o3itin>= ot0er t0an durin> -re>nan2
)his refers to constant or periodic unpleasant feelin$s in the stomach& an upset stomach. oods that ma/e the su+;ect ill should +e rated in #7!$&. #7!#) Con1ti-ation #7!#* Freuent loo1e
Complaints of fre=uent or loose +o*els or diarrhoea. #7!$! Diarr0oea #7!$" Di10ar>e of fluid1 fro3 anu1 #7!$# 5ad ta1te in 3out0= oated ton>ue
)his symptom may +e reported alon$ *ith other $astro-intestinal symptoms such as +elchin$& re$ur$itation of food& intolerance for several /inds of food or a+dominal cramps +ut should +e rated separately here. #7!$$ Aero-0a>2= 0iou>0 #7!$% 5urnin> 1en1ation in 0e1t or e-i>a1triu3 #7!$& Intolerane of 1e?eral different food1 #7!$' Ot0er >a1trointe1tinal o3-laint1
)his item covers symptoms not included in the precedin$ items. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O
Cannot +reathe easily smotherin$ or cho/in$ feelin$ difficulty in +reathin$ present *hen not ma/in$ much effort. #7!%! D21-nea on e.ertion #7!%" ,2-er?entilation #7!%# Ot0er ardio?a1ular o3-laint1
)his item covers symptoms not included in the precedin$ items. +ROGENITAL SYMPTOMS #7!%$ Freuent urination
re=uency of passin$ *ater& sense of ur$ency& or any similar urinary complaint. #7!%% +rine retention
#ifficulty passin$ *ater& retention. #7!%& +n-lea1ant 1en1ation1 in or around t0e >enital1 #7!%' +nu1ual or o-iou1 ?a>inal di10ar>e
8assin$ of fluid& usually *hitish in color and in small amounts from va$ina. )he amount of dischar$e is varia+le. !espondents *ho report this symptom often attri+ute their other +odily complaints to va$inal dischar$e. #7!%( Irre>ular 3en1truation #7!%) E.e11i?e 3en1trual #7!%* Redued 3en1trual flo;= a3enorr0ea #7!&! 4o3itin> durin> -re>nan2 #7!&" Se.ual indifferene
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 6 SO' S"<8)Oenital o3-laint1
)his item covers symptoms not included in the precedin$ items. NE+ROLOGICAL SYMPTOMS #7!&% Feelin>1 of i3-aired oordination or 1 of -are1i1 or loalied ;ea@ne11
)his $roup covers muscular *ea/ness ?either periodic or unremittin$@. pro+lems in liftin$& ina+ility to stand up or to *al/ or ina+ility to move any part of the +ody. #7!&' Diffiult2 1;allo;in> or lu3- in t0roat
eelin$ a lump in the throat ?$lo+us hystericus@. #7!&( A-0onia
oss of voice loss of speech and other pro+lems that relate to voice& pronunciation& etc. #7!&) +n-lea1ant nu3lin> 1en1ation1
,ncludes different sensations such as tin$lin$ ?sli$ht stin$in$ sensationEpins and needles@& cra*lin$ or creepin$ impressions as *ell as feelin$s of heaviness or li$htness any*here in the +ody. #7!&* Lo11 of tou0 or -ain 1en1ation
)his symptom covers loss of feelin$ in any part of the +ody ?num+ness& anaesthesia@. #7!'! Dou
)his symptom $roup includes +lindness in one or +oth eyes and other pro+lems *ith vision ?e0cludin$ +lurrin$ due to lac/ of proper $lasses& or dou+le vision@ #7!'# Deafne11
Covers loss of hearin$& rin$in$ or +u%%in$ in the ears or in the head. #7!'$ Diine11
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O #7!'& Lo11 of on1iou1ne11 ot0er t0an faintin>
)his symptom $roup covers any sort of loss or alteration of consciousness& includin$
li$ht-headedness& near-faintin$& trances& catalepsy& faintin$& passin$ out& convulsions& fits& spells of unconsciousness. #7!'' Lo11 of 3e3or2
oss of memory for certain ?often stressful@ events& coverin$ a period of hours or more. )he loss does not include anaesthesia for operations or durin$ convulsions or faintin$& or follo*in$ head in;ury. #7!'( Ot0er neurolo>ial o3-laint1
)his item covers symptoms not included in the precedin$ items. SKIN OR GLAND SYMPTOMS #7!') 5lot02 or di1olored 1@in
Chan$es in s/in color especially in patches. #7!'* Ede3a #7!(! E.e11i?e 1;eatin> #7!(" 5urnin>= it0in> #7!(# 5rea1t en>or>e3ent or 1eretion #7!($ Ot0er 1@in or >land o3-laint1
)his item covers symptoms not included in the precedin$ items. A+TONOMIC SYMPTOMS
Autonomic symptoms are specified as +ein$ particularly li/ely to +e associated *ith somatoform disorders. )hey must have the $eneral somatoform characteristics +ut they are other*ise identical *ith an0iety items %7!!% ?#7!(%& palpitations@& %7!"" ?#7!('& trem+lin$@& %7!"# ?#7!(& or #7!()& hot or cold s*eats or flushes@& and %7!!) ?#7!((& dry mouth not due to medication@. #7!(% ,eart -oundin> or aelerated -ul1e rate
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O or 10a@in> #7!(( Dr2 3out0 #7!() Flu10in> or #7!(* C0urnin> in 1to3a0=
)his item covers symptoms not included in the precedin$ items. #7!)" Ot0er 1o3atofor3 123-to31= 1-eif2/ 777777777777777777777777777
)his item covers symptoms not included in the precedin$ items. #7!)# Len>t0 of di1tre11 due to -reou-ation B3ont01 )his item refers to any symptoms rated present at #7!"! 6 #7!)"& *hich distress
the !espondent +y their persistence& althou$h no e0planation for them has +een provided. 'nter the num+er of months that the symptoms have +een present. #7!)$ 4aria
Somatoform symptoms tend to +e multiple +ut are not necessarily present to$ether at
one time. !ate the fre=uency of variation. #7!)% So3atofor3 or 02-o0ondriaal -reou-ation )he symptom has the characteristics of *orryin$ ?see $7!!"@ +ut is also distin$uished
?,@ 4y an intense preoccupation *ith apparently normal sensations or physical si$ns or appearances& *hich are interpreted in terms of no more than one or t*o particular named serious physical illnesses or deformities. ?ii@ 4y persistence of the preoccupation in spite of ade=uate and repeated investi$ation& and e0pert advice that it is $roundless. Althou$h there are often +rief periods of relief immediately follo*in$ such reassurance& and the de$ree of conviction varies& the round of painful and distressin$ *orry returns. ' S"<8)O
,f there is true conviction of the presence of a none0istent disease& rate at item #7!)' ?repeated at "*7!#) and& if in conte0t of depressed mood& at "*7!#( @. Somatic hallucinations and delusional ela+oration are rated at "(7!#) and "(7!#* . 8ho+ias of contractin$ disease ?%7!%%@& or of medical situations ?%7!%$@& should +e distin$uished if they lac/ the t*o characteristics specified a+ove. O+sessional preoccupation *ith the possi+ility of harm from contamination or infection ?&7!!&@& must have the characteristic resistance a$ainst su+;ective compulsion. )he differentiation from pho+ias and o+sessions can +e difficult. ,f criteria for more than one symptom are satisfied& each should +e rated on its merits. One does not e0clude the others. #7!)& Duration of 02-o0ondriaal -reou-ation B3ont01
!ate duration in months. A+sent M :::. #7!)' So3atofor3 or 02-o0ondriaal
When hypochondriacal preoccupation is most severe it ta/es the form of refusal of medical reassurance& *ith a +elief that disease is present even *hen no a+normality is found in repeated e0aminations. !espondents may +elieve that one ?or perhaps t*o@ diseases account for the symptoms and are not satisfied *ith the *ay that medical e0perts have handled the case or *ith the conclusions and e0planations offered. )hey may contact one doctor ?or other healer@ after another and accept many treatments +ut re;ect assurances that there is no ade=uate physical cause for the symptoms or presumed deformity& e0cept for short periods follo*in$ or durin$ medical investi$ations or interventions. Differentiation fro3 ot0er 123-to31/
#ifferentiation from pho+ias and o+sessions should not +e difficult. Hypochondriacal delusions are rated at "*7!#) or at "*7!#( if in conte0t of depression. ,f it is difficult to +e sure of the presence of delusional conviction& rate as item #7!)%. FATIG+E SYNDROME
!ate items #7!)( 6 #7!)*= #7!*"6#7!*' and #7!*) : A+sent. 1 8resent. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 5 SO' S"<8)O fati>ue B-021ial e.eri1e
9n*arranted fati$ua+ility after even minor physical e0ertion. )he emphasis is on feelin$s of +odily or physical *ea/ness and e0haustion after only minimal effort& accompanied +y a feelin$ of muscular aches and pains. !espondents e0perience the tiredness as unpleasant and distressin$. Differentiation fro3 ot0er 123-to31/
)iredness at the end of a hard day of physical *or/ ?rate :@& or due to the after-effect of influen%a& *ould not count. )he level of increase in fati$ua+ility should +e assessed a$ainst relevant previous e0perience& such as *al/in$ a familiar distance& clim+in$ stairs& etc. #ifferentiate from item $7!!(& *hich is not necessarily related to physical e0ercise. A clinical decision should +e made *hen the disorder has +een attri+uted +y e0perts to a viral aetiolo$y. !ate for or$anic attri+ution at items #7"#% and #7"#& or at item level usin$ optional attri+utional ratin$ scale. #7!)) E.e11i?e and di1tre11in> fati>ue B3ental e.eri1e
)he main feature is e0cessive mental fati$ue follo*in$ even minor mental e0ercise. )his is typically descri+ed as an unpleasant intrusion of distractin$ associations or recollections& difficulty in concentratin$& focusin$ and sustainin$ attention& and $enerally inefficient thin/in$. )he condition is usually associated *ith decreased efficiency in copin$ *ith daily tas/s. Differentiation fro3 ot0er 123-to31/
)iredness at the end of a hard days mental *or/ ?rate :@& or due to the after-effect of influen%a ?rate (@& *ould not count. )he level of increase should +e assessed a$ainst relevant previous e0perience& such as readin$ a +oo/& doin$ calculations& etc. #ifferentiate from item $7!!(& *hich is not necessarily related to mental e0ercise. !ate for or$anic attri+ution as mentioned a+ove. #7!)* Inaue
,na+ility to restore mental and physical ener$y after e0cessive fati$ue follo*in$ even minor e0ercise. )his is a prolon$ation& lastin$ days or lon$er& of the symptom rated at items #7!)( and #7!)). )he sense of tiredness is usually accompanied +y feelin$s of muscular aches and pains& and the !espondent is una+le voluntarily to overcome it. A main feature is ina+ility to rela0 fully. #ifferentiate from normal sleepiness and from item $7!!(& *hich is not necessarily related to e0ercise. !ate : if ! is a+le to recover normally from fati$ue. #7!*! Duration of fati>ue 12ndro3e B3ont01
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O
SYSTEM65ASED SYNDROMES
A mar/ed preoccupation *ith $roups of somatic symptoms that are all related to one particular +odily system or or$an ?usually one lar$ely under autonomic control@& thus partly mimic/in$ a physical disorder of that system or or$an. )he symptoms are +ased on si$ns of autonomic arousal of the system. #7!*" ,eart and ardio?a1ular
#a Costa syndrome& cardiac neurosis& neurocirculatory asthenia. #7!*# Re1-irator2 121te3
Hyperventilation& etc. #7!*$ Oe1o-0a>u1 and 1to3a0
8sycho$enic fre=uency& psycho$enic dysuria& etc. #7!*' General autono3i d21funtion
Covers preoccupation *ith autonomic symptoms spannin$ more than one or$an system. #7!*( Duration of >eneral autono3i d21funtion B3ont01
!ate duration in months. A+sent M :::. #7!*) Pain 12ndro3e
)he predominant complaint is a persistent and distressin$ pain that cannot +e e0plained +y a physical disorder& occurrin$ in association *ith emotional conflict or psychosocial pro+lems. )he stress caused +y these emotional or psychosocial pro+lems should +e sufficient to allo* the conclusion that they are the main causative factors. #7!** Pain 12ndro3e duration
#uration in months. A+sent M :::. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 6: SO' S"<8)O
)hese are symptoms ori$inally caused +y& or associated *ith& some physical disorder& *hich are e0a$$erated or prolon$ed +y psycholo$ical factors such as possi+le financial compensation& fear of death or disa+ility& or hope for more successful treatment. ?)his item is repeated at #(7!'* +ecause of the need for information from other sources.@ Differentiation fro3 ot0er 123-to31/
)he main difference is from malin$erin$. A clinical ;ud$ement has to +e made in the li$ht of all the evidence as to *hether the motivation is or is not fully conscious. See the $eneral comments under #issociative Symptoms& +elo*. #7"!" Fatitiou1 di1order
A persistent pattern of intentional production or fei$nin$ of symptoms andEor selfinfliction of *ounds in order to produce symptoms in the a+sence of a confirmed physical
or mental disorder. ?)his item is repeated at #(7!') +ecause of the need for information from other sources.@ Differentiation fro3 ot0er 123-to31/
,f evidence can +e found for a conscious e0ternal motivation ?such as financial compensations& escape from dan$er& or more medical care@ the appropriate code is for malin$erin$ ?7.3 in ,C#-1:@. DISSOCIATI4E SYMPTOMS
#issociative symptoms are all characteri%ed +y a partial or complete disconnection +et*een memories of the past& a*areness of identity and of immediate sensations& and control of +odily movements. Conscious control over *hich memories and sensations can +e selected for immediate attention& and *hat movements can +e car ried out& is impaired& althou$h varyin$ in de$ree from day to day and even from hour to hour. )he severity of impairment is often difficult to determine clinically. )he terms hysteria and conversion are avoided in ,C#-1:& and dissociative symptoms are presumed to +e psycho$enic in ori$in& +ecause closely associated *ith traumatic events& intolera+le or insolu+le pro+lems& or distur+ed relationships. No particular theory of the mechanisms underlyin$ dissociation is assumed for purposes of this Glossary +ut secondary $ain is a su$$estive feature. 8eople *ith dissociative symptoms often deny pro+lems that are o+vious to others. An informant is then essential for proper ratin$. See also items "(7!#!& dissociative hallucinations& and #!7!#' 6 #!7!#*& *hich constitute the Chec/list for ,nduced 8sychosis. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O
#epersonali%ation and dereali%ation are not associated *ith loss of conscious control over access to sensations& memories or movements& and only limited aspects of personal identity are affected. ,n depersonali%ation& there may +e a loss of the sense of self& +ut the people affected /no* *ho they are.
#7"!# Di11oiati?e a3ne1ia
)he main feature is loss of memory& usually of important recent events& not due to or$anic mental disorder and too $reat to +e e0plained +y ordinary for$etfulness or fati$ue. )here is no inte$ration of present e0periences *ith memories of the past. )he amnesia is presumed to +e of psycho$enic ori$in o ri$in and is usually partial and selective. )he main pro+lem is not in the re$istration or retention of the memory& +ut in the rec all of facts usually associated *ith insolu+le or unaccepta+le interpersonal pro+lems& or traumatic events such as accidents or une0pected +ereavements. )he loss of memory may +e an e0pression of emotional needs or failure of effective copin$ mechanisms. Differentiation fro3 ot0er 123-to31/
)here should +e no evidence of a physical disorder that can e0plain the symptoms that characteri%e the disorder. Amnesia induced +y alcohol or dru$s& or +y postictal amnesia in epilepsy& should not +e included here. Similarly su+;ective complaints of loss of memory ?difficulty in recollection of important facts and events@ e0perienced in depressive disorders should +e distin$uished. #7"!$ A3ne1ia entered around reent 1tre11 As item #7"!# convincin$ly associated in time *ith traumatic events& distur+ed social
relationships or insolu+le pro+lems. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 62 SO' S"<8)Oue
Apparently purposeful travel +eyond the usual everyday ran$e in an amnesic state. )he su+;ects +ehavior durin$ the fu$ue may appear completely normal to independent o+servers. Ho*ever& respondents display a complete dissociative amnesia a+out the events durin$ that period. )here should +e evidence for psycholo$ical causation in the form of convincin$ associations in time *ith stressful events& pro+lems or needs. #7"!& Di11oiati?e 1tu-or
A condition of psycho$enic ori$in in *hich there is a profound diminution or a+sence of voluntary movement and normal responsiveness to e0ternal stimuli such as li$ht& noise and touch. )he muscle tone is maintained to$ether *ith normal +reathin$ and limited coordinated eye movements. )here should +e positive evidence of psycho$enic causation in the form of recent stressful events or pro+lems and a clear-cut a+sence of evidence for a physical cause. Differentiation fro3 ot0er 123-to31/
)his condition should +e distin$uished from a/inetic mutism #"7!$!& catatonia ?items ##7!#% 6 ##7!$'@ and stupor ?##7!!' @. #7"!' Trane e.-eriene
A temporary loss of the sense of personal identity and loss of full a*areness of the surroundin$s or limitation of movements& postures& and speech to repetition of a small repertoire narro*in$ of a*areness or selective focusin$ limited movement& or restriction of posture and speech to a small repertoire.
)he e0perience is un*anted& trou+lesome& and not part of& unless an un*anted prolon$ation of& a reli$ious or culturally accepted ceremony cer emony or situation. !ate trance only& *hether or not there is a possession e0perience& #7!"!( Po11e11ion e.-eriene
A feelin$ that the individual has +een ta/en over& *ithout *ishin$ it& +y a spirit& po*er& deity or other person. #istin$uish from fr om alienation e0periences as descri+ed in Section 15. )he e0perience is un*anted& trou+lesome& and not part of& unless an un*anted prolon$ation of& a reli$ious or culturally accepted ceremony cer emony or situation. !ate possession e0perience only& *hether or not there is a trance. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)O
un*anted and trou+lesome. #7"!* Di11oiati?e on?ul1ion1
8seudosei%ures. Convulsions may mimic epileptic sei%ures in *hich *hole or parts of the +ody sha/es. Ho*ever& dissociative convulsions are usually lon$er in duration& and ton$ue-+itin$& +ruisin$ due to fallin$& incontinence of urine are rare ?+ut can occur@. )here is not a true loss of consciousness& +ut a state of trance or dissociative stupor. A positive ratin$ should not +e made *ithout full neurolo$ical investi$ation& resultin$ in no evidence of or$anic disorder. 8seudosei%ures may +e present in individuals *ith true epilepsy& complicatin$ differentiation. #7""! Di11oiati?e 1en1or2 lo11 or anae1t0e1ia
)here is a declared sensory loss on the s/in *hich often has +oundaries that do not fit into any neurolo$ical deficit. )hese may +e associated *ith different sensations li/e tin$lin$ or other paraesthesias. )here may +e differential loss +et*een the sensory modalities ?touch& pain& heat& vi+ration& etc.@ *hich cannot +e due to a neurolo$ical pro+lem. )his item also covers the partial or complete loss of vision& hearin$ or smell *hich is of psycho$enic ori$in. 4e*are of sophisticated su+;ects *ho have /no*led$e of patterns of neurosensory distri+utions. #7""" Di11oiati?e di1order of ?oluntar2 3o?e3ent
)he loss of a+ility to move the *hole or a part of +ody or lim+s. )his item also includes speech. )hese may mimic any neurolo$ical deficit such as astasia& a+asia& a/inesia& apra0ia& aphonia& dysarthria& dys/inesia& paraparesis or paralysis. #7""# A11oiation of di11oiati?e 123-to31 ;it0 1tre11
All dissociative disorders are presumed to +e of psycho$enic ori$in. Onset is convincin$ly associated in time *ith a traumatic life event& *ith intolera+le or insolu+le pro+lems& or *ith distur+ed interpersonal relationships& *hich *h ich ! may not ac/no*led$e or
+e a*are of. oss of consciousness cons ciousness or any other +odily function may +e a si$n of emotional need or conflict. A disinterested informant is usually necessary. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 66 SO' S"<8)O
)here should +e no evidence of a physical disorder that can e0plain the symptoms that characteri%e the disorder ?+ut physical disorders may +e present that $ive rise to other symptoms@. SKIP 89 to #7!'% if 1o3atofor3 li1t Bite31 #7!"! 6 #7!)" identifie1 no -ro
)he e0istence of t*o or more distinct personalities *ithin the individual& only one +ein$ evident at a time. 'ach personality has its o*n memories& pref erences and +ehavior patterns& and at some time ?and recurrently@ ta/es full control of the individuals +ehavior. )here is ina+ility to recall important personal information *hich is too intensive to +e e0plained +y ordinary for$etfulness. )he condition is of psycho$enic ori$in. )he personalities are not merely different facets of a sin$le personality disorder +ut are distinct coherent identities& each *ith an endurin$ pattern of perceivin$& relatin$ and thin/in$. #7""$ T;o or 3ore di1rete -er1onalitie1 #7""% Ea0 -er1onalit2 i1 o3-lete #7""& Ea0 -er1onalit2 3anife1ted <2 di1rete -eriod1 of ontrol of etfulne11 ;it0 ina
)his is a residual cate$ory to include transient amnesic or trance states of adolescence& Gansers syndrome& poorly differentiated multiple personality& depersonali%ation dereali%ation disorder& psycho$enic confusion and t*ili$ht states. All occur in circumstances su$$estive of a psycho$enic aetiolo$y and there are usually other dissociative symptoms. !ate culture specific dissociation disorders here& such as atah& 8i+lo/to& 9fufuyana& Sa$a. AGES OF ONSET
)hese may +e appro0imate +ut if there are somatoform or dissociative symptoms it is more useful to enter an estimated a$e ?say& *ithin 3 years@ than to leave the +o0es +lan/. ,f any estimate could +e $rossly *ron$& enter 55. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 SO' S"<8)Oe at on1et of -re1ent 1o3atofor3 di1order #7""* A>e at fir1t on1et of 1o3atofor3 di1order #7"#! A>e at on1et of -re1ent di11oiati?e di1order #7"#" A>e at fir1t on1et of di11oiati?e di1order
#7"## Ti3in> of PERIOD1 of Setion # 123-to31
,t is necessary to record only if dates of symptoms in this Section are different from 8'!,O# rated in Section 1 ?items "7!!(6"7!"% @. #7"#$ Interferene ;it0 ati?itie1 due to Setion # 123-to31
)his item relates to the interference *ith normal& everyday activities and roles due to the presence of various symptoms in Section 2. !ate the actual de$ree of interference due to Section 2 symptoms usin$ the scale in the manual. #7"#% Or>ani au1e of an2 Setion # 123-to31
General rules for ratin$ attri+utions of cause are to +e found in Section 1 of the ani au1e of Setion # 123-to31
or identifia+le causes& enter ,C#-1: chapter letter and up to 6 di$its. ,f none leave +lan/. #7"#' Su<linial infetion or nutritional -ro
,f li/ely to +e a contri+utory cause of any somatoform item in Section 2 that have +een rated as present& rate 1. #7"#( Relation of 1o3atofor3 123-to31 to -ani atta@1
8reoccupation *ith somatoform symptoms may occasionally occur in a similar time pattern to panic attac/s ?%7!#!@ and for the purposes of classification it is necessary to rate *hether these t*o forms of symptom presentation occur to$ether. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 6 WO!!",NG& )'NS,ON& ')C. $ Worr2in>= ten1ion= et7 GENERAL POINTS A5O+T SECTION $
Section contains items that are often classified as neurotic. Non-specific is a +etter term& since most of them can occur alone& or o r in association *ith each other& and in the a+sence of more specific symptoms such as an0iety or depression. )he latter disorders& on the other hand& are fre=uently accompanied +y a ran$e of non-specific dysfunctions. )he non-specific items& and many neurotic items& tend to +e characteri%ed +y three features that are fre=uently fre=uen tly mentioned in the follo*in$ definitions. )hey are painful e0periences they cannot +e fully prevented prev ented or controlled +y conscious effort effo rt and in severity and persistence they are out of proportion to any circumstances that appear to precipitate them.
adolescence or +efore. Symptoms ?rated 1 to accordin$ to severity@ should only +e rated if there has +een an onset a definite departure from an earlier symptom-free state. See !atin$ Scale , for further details. Ho*ever& if the date of definite onset can +e esta+lished& it may +e possi+le to record this at $7!"%& if most of the items in Section follo* that time course. ,f only one or t*o items have a protracted duration the date of the 8'!,O# should not +e altered. $7!!" Worr2in>
8erhaps the most u+i=uitous psychiatric symptom& +ut *ith no dia$nostic si$nificance in itself. ,t demonstrates ?re$ardless of content@ three central principles that are characteristic of many non-specific and neurotic symptoms 1 A round of painful& unpleasant or uncomforta+le thou$ht 2 *hich cannot +e consciously controlled +y tryin$ to turn the attention to su+;ects that *ould usually +e a+sor+in$ and is often out of proportion to the topic *orried a+out& so that the person affected appears consumed *ith *orry a+out a triviality. Worry can +e rated *hen the su+;ect is painfully and uncontrolla+ly concerned a+out a serious matter& li/e the death of a near relative& or the conse=uences of redundancy& +ut the intervie*er should then +e very sure that the *orry is out of proportion for e0ample& it lasts lon$er than e0pected& or seriously impairs effective mental functionin$. 8eople may *orry a+out their o*n mental state& or a+out their lac/ of ener$y or social inade=uacy& or their psychotic e0periences. )he content of the *orry is not relevant to reco$nition of its form. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 WO!!",NG& )'NS,ON& ')C. 67 )he numerical ratin$ re=uires the e0aminers ;ud$ement as to ho* severe and ho* prolon$ed the *orryin$ has +een durin$ the period under revie*. Differentiation fro3 ot0er 123-to31/
)his symptom accompanies& and can +e a precursor to& many others& such as hypochondriasis& depression& o+sessions& and pho+ias& +ut it lac/s their specific features. ,t occurs most commonly in the $eneral population *ith other symptoms in Section of 8S'1: for e0ample& muscular and nervous tension& e0haustion& and self-consciousness. $7!!# Feelin> of ner?ou1 ten1ion
A feelin$ of inner restlessness or unease e0pressed in terms such as nerves& +ein$ on ed$e& +ein$ /eyed up. ?4ein$ up-ti$ht or *ound-up implies a de$ree of muscular tension as *ell and the t*o symptoms commonly co-e0ist.@ Nervous tension is a state of arousal that has three +asic characteristics of many nonspecific and neurotic symptoms - it is unpleasant& not under voluntary control and not fully e0plica+le in situational terms. )here is li/ely to +e an e0a$$erated startle response. Autonomic symptoms such as are dealt *ith in Section 6 may or may not +e fran/ly present they are not a re=uirement for the symptom. Nervous tension is not lin/ed to any particular mental content thou$h it often does accompany symptoms such as *orry and
an0iety& and may appear as a precursor to them. Differentiation fro3 ot0er 123-to31/
and should +e rated independently. Nervous tension should +e differentiated from An0iety ?item %7!#$@ and An0ious fore+odin$ ?item %7!#%@& for *hich clear-cut autonomic symptoms must +e present. Normal situational nervousness& such as +ein$ /eyed up +efore ta/in$ an e0amination& should +e rated :& not 1. $7!!$ General 3u1ular ten1ion
An unpleasant tension in one or more $roups of muscles& *ith ina+ility to rela0 voluntarily. )he muscular tension is not related to any specific intended muscular effort. Almost any $roup of muscles can specifically +e affected ?see item $7!!&@& +ut in the present item only $eneral tension is rated. !ate on the +asis of fre=uency and intensity durin$ the past month. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 65 WO!!",NG& )'NS,ON& ')C. Differentiation fro3 ot0er 123-to31/
fe* symptoms ?e.$. in population samples@ to e0press a positive rather than a purely ne$ative evaluation of their mental functions. )his can also +e true of those *ith symptoms that do not e0clude positive functionin$ in some areas. )he items are also helpful in confirmin$ cut-off points. Note the unusual ratin$ scale& to avoid the possi+ility of misleadin$ default ratin$ of :. $7!!& Loalied ten1ion -ain1
)his symptom is muscular tension ?item $7!!$@ locali%ed to particular muscle $roups. One of the commonest complaints is of headache li/e a +and round the temples or a *ei$ht pressin$ do*n on the head& due to tension in the muscles of the scalp. )hose afflicted are often clear a+out the relationship of the headache to muscular ?and nervous@ tension. Write do*n the locali%ation of the tension pains *henever this item is rated as present. Other common locali%ations are the +ac/& the nec/ and the shoulders. Chest pain may also +e due to muscular tension. )ension pains occurrin$ only once or t*ice a month should +e rated 1. Differentiation fro3 ot0er 123-to31/
4e careful to e0clude mi$raine and other /no*n causes of headache. $7!!' Su<eti?el2 de1ri
sho*n +y fid$etin$ of various parts of the +ody and an ina+ility to stay still. ,n severe
de$ree it is e0pressed +y pacin$ up and do*n& *anderin$ a+out& ina+ility to sit do*n for very lon$. )hree common criteria for non-specific symptoms must +e met - the restlessness is e0perienced as unpleasant& it is not under voluntary control& and it is inappropriate to the situation respondents find themselves in. )he ratin$ of severity is +ased on the respondents o*n account of fre=uency and intensity durin$ the past month. ,f independently o+served to +e present durin$ the past month or at intervie*& rate at item ##7!"&. Differentiation fro3 ot0er 123-to31/
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 WO!!",NG& )'NS,ON& ')C. 6( !estlessness ?##7!"&@& A$itation ?##7!"'@ and Overactivity ?##7!"(@ can +e +ehavioral manifestations of su+;ective restlessness +ut they may also +e associated *ith a feelin$ of ener$y and need not +e su+;ectively unpleasant. )hey should +e rated on the +asis of o+served +ehavior alone. ,tem $7!!' should only +e rated from the respondents su+;ective description. )he symptom must +e distin$uished from a/athisia due to neuroleptic medication& *hich is also often su+;ectively unpleasant. ,f the respondent clearly and convincin$ly relates this restlessness to such medication rate etiolo$ic attri+ution. Chec/ +y as/in$ respondent to stand still for a *hile& somethin$ that is much more difficult in a/athisia than in psycho$enic restlessness. See also the $uide to motor e0amination in item #"7!(%. $7!!( Fati>ua
A symptom often accompanyin$& and in part due to& symptoms such as muscular tension ?$7!!$@& restlessness ?$7!!'@& and *orryin$ ?$7!!"@. ,t should +e rated independently. )hree common criteria for a non-specific symptom should +e met su+;ects e0perience the fati$ue as unpleasant& they are una+le voluntarily to overcome it and it is inappropriate to the situation they find themselves in. )hus tiredness and sleepiness at the end of a hard days *or/& or due to the after-effect of influen%a& *ould not count. )he tiredness is essentially a sense of mental and physical fati$ue *orn out& lethar$ic& heavy - not merely sleepy. ,t can& ho*ever& accompany chronic loss of sleep. )he most intense form of the symptom is e0haustion. Differentiation fro3 ot0er 123-to31/
Althou$h it is possi+le to fall asleep as the result of +ein$ immo+ili%ed +y physical fati$ue& the symptom should +e distin$uished from sleepiness& and still more from hypersomnia ?see item )7!"'@. '0cessive fati$ue follo*in$ e0ercise is rated at items #7!)(= #7!))= and #7!%#. ,f the tiredness is due to a physical cause& includin$ medication or a viral infection& rate etiolo$ic attri+ution. $7!!) Sen1iti?it2 to noi1e
)he s=uea/in$ or $ratin$ noise that chal/ sometimes ma/es on a +lac/+oard has an unpleasant =uality to *hich some people are particularly sensitive. A similar =uality may accompany any undifferentiated noise& such as car or plane en$ines& or loud music. 'ven
noises that many people *ould find tolera+le may have this =uality for some. )he respondent may say noises $o ri$ht throu$h me& it ;ars on me& , cannot stand it *hen a plane $oes over. )he e0perience is unpleasant and distractin$& and leads to avoidance of noisy environments. Anticipation of unpleasant noise may +e as distractin$ as the noise itself. 4e careful to consider the actual noise level e0perienced. A ratin$ of ?1@ is used *hen there is an une=uivocally hi$her sensitivity than normal +ut this does not interfere WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 3: WO!!",NG& )'NS,ON& ')C. *ith everyday activities. A ratin$ of ?@ is reserved for e0treme sensitivity to noises that most people *ould not find intolera+le so that there is su+stantial interference *ith activities. Differentiation fro3 ot0er 123-to31/
)he symptom is sensitivity to noise& not simply disli/e of loud noises. #o not ta/e other symptoms& such as irrita+ility& into account. )hey should +e rated independently. ,f difficult to differentiate in a case of tinnitus& or hyperacusis due to middle ear disease& consider ratin$ for or$anic attri+ution. $7!!* Irrita
A su+;ective& painful feelin$ of irrita+ility& *ith a tendency to respond to minor annoyances. )he response is e0cessive& out of proportion to the circumstances and difficult to control. !ate an increase in irrita+ility durin$ the chosen episode compared *ith respondents norm. ,f this is mainly su+;ective& *ithout much e0ternal evidence& apart perhaps for a fe* minor domestic =uarrels& rate ?1@. ,f it is sho*n +y a fre=uently raised voice& shoutin$ or a readiness to pic/ =uarrels +ut *ithout violence& rate ?2@. ,f there is loss of control& *ith pushin$ or hittin$& rate ?@. ,f there is no e0acer+ation associated *ith an episode of psychiatric distur+ance& +ut an e0pression of the usual personality& rate for attri+ution. Ho*ever& if symptoms throu$hout the Section appear to date +ac/ to early life& and fulfill the criteria of symptoms durin$ the 8'!,O#& rate presence and severity and consider ratin$ the date of onset at $7!"%. !ate accordin$ to !s o*n account. Differentiation fro3 ot0er 123-to31/ ,rrita+le mood ?"!7!!#@ is a manic symptom and should +e differentiated from a
su+;ective feelin$ of irrita+ility& if possi+le. ,rrita+le mood is a pervasive mood of irrita+le& irasci+le erethism or e0cita+ility& an$ry impatience& hair splittin$ =uerulance& hasty temper and easily aroused a$$ressiveness. )he patient is +ein$ on a short fuseP& +oilin$ up insideP. Su+;ectively& the patient may or may not feel irrita+le& +ut may descri+e that other people find him inpatient& *ith a hasty temper or a$$ressive. 4oth symptoms may+e present and should +e rated separately. Consider patholo$ical response to alcohol ?""7!#(@& and if present rate usin$ etiolo$y option if it completely accounts for the +ehavior. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1
WO!!",NG& )'NS,ON& ')C. 31 )he follo*in$ items $7!"!= $7!""& and $7!"$ represent overvalued ideas i.e.& they are ideas in *hich the individual has invested lot of emotion and they are in the forefront of the su+;ects psyche. 'ven thou$h he reco$ni%es that they are not true he cannot help feelin$ li/e that and perhaps even acts on them. $7!"! Si3-le idea1 of referene
,n its moderate form ?rated 2@& this symptom is indicated +y self-consciousness. )hose afflicted cannot help feelin$ that people ta/e notice of them - in +uses& in a restaurant& or in other pu+lic places - and that aspects of themselves that they *ould prefer not to +e noticed are someho* pu+licly o+serva+le. )he accompanyin$ $uilt or shame is out of proportion compared to any possi+le cause& *hich may +e no more than a tendency to +lush easily. )hey reali%e that such feelin$s ori$inate *ithin themselves +ut the insi$ht is of little value. )he e0perience may accompany depression +ut is not solely the result of the mood chan$e. ,n its severe form& ! may complain of a feelin$ of +ein$ lau$hed at or critici%ed& perhaps +ecause of some peccadillo that others seem to /no* a+out. A$ain& there is insi$ht into the true nature of the symptom& +ut it tends to vary and reassurance is rarely fully effective. ,f a respondent does& in fact& have some distin$uishin$ physical characteristic that mi$ht cause notice& rate ?5@ unless the su+;ects distress and lac/ of control of the self-reference is out of proportion. Differentiation fro3 ot0er 123-to31/
#o not include delusions of reference ?items "*7!!%= "*7!"!= "*7!"" @& in *hich respondents +elieve that events refer to them personally and have no insi$ht into the ori$in of the self-reference *ithin themselves. #ifferentiate from delusional ideas of reference& in *hich the conte0t of depressive $uilt feelin$s or e0pansive mood are primary. #istin$uish also from social pho+ias ?items %7!$$ 6 %7!$'@& *hich may co-e0ist and should +e rated independently& and dysmorphopho+ia ?item "'7!""@& in *hich self-reference is +ased on a feelin$ that the afflicted persons features have chan$ed in some *ay. $7!"" Su1-iiou1ne11
)his symptom usually accompanies a disorder such as depression& hypomania& delusional psychosis& schi%ophrenia or co$nitive impairment. Ho*ever it should only +e rated present if there is a de$ree of insi$ht concernin$ its internal ori$in either an attri+ution to a mood chan$e or failin$ memory& or simply a /no*led$e that it has no ?or insufficient@ e0ternal ;ustification. Severity depends on the e0tent to *hich insi$ht is partial and on the +ehavior that occurs *hen it lapses. ,tem #$7!"* should +e rated if suspiciousness is rated in +ehavior at e0amination or reported in case records or +y an informant durin$ the past month. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 32 WO!!",NG& )'NS,ON& ')C. Differentiation fro3 ot0er 123-to31/
Suspicion may +e re$arded as a symptom in mania. ,f necessary it should +e revie*ed a$ain *hen Section 1: is +ein$ used. #ifferentiation from delusions of persecution should +e made accordin$ to the criteria at the +e$innin$ of Section 1(. $7!"# De-er1onaliation and derealiation
)he symptom is +ased on a detachment from& or loss of& the emotional colorin$ that accompanies the consciousness or perception of self. #ereali%ation is a related symptom in *hich events or o+;ects or people in !s environment are e0perienced as unreal. Opportunity to rate these phenomena in more detail is provided in Section 1& *here further items are included to rate depersonali%ation itself. Section 1 should al*ays +e rated if there is any indication of perceptual a+normalities. )he Glossary for Section 1 items should +e consulted& +ecause other perceptual a+normalities may mimic depersonali%ation. ! retains a de$ree of insi$ht& /no*s the condition is a+normal& and descri+es it in as if terms. )he e0perience is one of feelin$ oneself or the surroundin$s unreal. Differentiation fro3 ot0er 123-to31/
)he +asic e0perience of depersonali%ation ?emotional detachment from the perception of self@ may occur as part of an an0iety state or panic state& characteristically terminatin$ the an0iety. )his should +e rated separately or additionally at item %7!#'. ,t is also specified as an an0iety symptom in some dia$nostic rules& and is therefore included at %7!"$. $7!"$ Non6delu1ional ealou12
! is preoccupied *ith thou$hts that a se0ual partner is& or mi$ht +e& +ein$ unfaithful& in spite of lac/ of evidence and assurances of fidelity. )he de$ree of conviction varies& +ut it usually ta/es the form of dou+t& *ith only fluctuatin$ certainty. )he a$ony of dou+t can lead to determined attempts to resolve the uncertainty +y see/in$ evidence& loo/in$ for stray hairs on clothin$ inspectin$ diaries secretly follo*in$ the partner tryin$ to interpret *hether stains found on underclothin$ are si$ns of illicit se0ual activity. Severity is rated accordin$ to the e0tent and nature of activities desi$ned to end uncertainty. Differentiation fro3 ot0er 123-to31/
Since people *ho do have $rounds for ;ealousy can +ehave in a similar *ay and the importance placed on infidelity varies +et*een cultures and +et*een se0es& caution should +e used *hen ma/in$ a ratin$. )he most clear-cut si$ns of mor+id ;ealousy are seen in WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 WO!!",NG& )'NS,ON& ')C. 3 the delusional forms. ,f there is any possi+ility of this& ratin$ should +e deferred until items "*7!"% and "*7!"&. )he Glossary definition of item "*7!"%& delusional ;ealousy& is relevant. $7!"% Ti3in> of PERIOD1 of Setion $ 123-to31
,t is important to ma/e a record here if the dates of symptoms in the Section are
clearly different from those already recorded for 8S or !' E 4 in Section 1. or e0ample& a respondent *ho has recently developed a depressive episode may also have had positive items in this section that +e$an many years previously& possi+ly durin$ childhood or adolescence. or a short episode of symptoms it is necessary to record onset in days so that data is availa+le to determine if duration meets dia$nostic criteria. or depressive episodes it is important to determine if the duration has +een 16 days or lon$er. $7!"& Interferene ;it0 ati?itie1 due to Setion $ 123-to31
)his item is self e0planatory and is important for certain classification systems and for descriptive purposes. ,t also ma/es clear that interference is rated separately. $7!"' Or>ani au1e of 123-to31 in Setion $ $7!"( Identif2 or>ani au1e of Setion $ 123-to31
,tems in Section may +e present +ut in the ;ud$ement of the intervie*er may +e the result of a separate physical cause or dru$. ,f this occurs& use the optional attri+utional etiolo$y +o0es for items andEor the more $eneral ratin$s in Section 1. #o not rate a symptom as a+sent simply +ecause of a suspicion that a physical or other e0ternal factor may have contri+uted to it. )he etiolo$y option is desi$ned to allo* separate ratin$s of phenomenolo$y and etiolo$y.
)he Section has t*o ma;or parts the first dealin$ *ith panic attac/s ?*hether or not in pho+ic situations@ and more $enerali%ed an0iety& the second *ith pho+ias ?or pho+ic avoidance@. )he first t*o items& a+ove the cut-off point& are pro+es for the t*o main types of symptom. As usual& the cut-off point is crossed if there is any dou+t as to *hether either type of symptom is present. )he an0iety su+section +e$ins *ith a list of an0iety symptoms& *hich can +e presented as a card or read out +y the intervie*er. )his is follo*ed +y items representin$ various /inds of an0iety +ased on autonomic im+alance. )he severity of each can +e rated independently of the others. )here is one course item ? %7!#&@. Such items are placed throu$hout the 8S'1: te0t& and must al*ays +e rated if the intervie* $oes +eyond the cut-off point& since they are used for classification purposes +y computer al$orithms. ,f there have +een no an0iety symptoms durin$ the period under revie* +ecause ! has avoided the situations that provo/e them& there is a s/ip to the su+section on pho+ias. )his +e$ins *ith three lists representin$ situational& social and specific ?simple@ pho+ias& follo*ed +y items to rate the most severe e0ample of each& items to measure de$ree of pho+ic avoidance and interference. Course items follo* ?all important for dia$nostic al$orithms@.
%7!!" General ratin> of an.iet2 %7!!# General ratin> of -0o
8ro+e =uestions *hich& to$ether *ith any other information availa+le& help determine *hether the cut-off point should +e passed. %7!!$ 6 %7!"* An.iet2 123-to31
)his list of an0iety symptoms& *hen not clearly due to physical factors or to appropriate environmental circumstances& is the +asis ?al+eit& occasionally& throu$h attempts to avoid them@ for the definition of panic attac/s& free-floatin$ an0iety& an0ious fore+odin$ and in some classification systems& pho+ias. 9se optional attri+utional etiolo$y +o0es if due to identifia+le physical factors. )he criteria for ratin$ physical cause are very strictly laid do*n ?Section 1@ and it may +e necessary to rate a $eneral physical attri+ution of cause in Section 1. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 8AN,C& ANQ,')"& AN# 8HO4,AS 33 %7!#! Freuen2 of -ani atta@1 ;it0 autono3i 123-to31
8anic attac/s are discrete episodes of mar/ed autonomic an0iety& *ith a sudden onset& +uildin$ rapidly ?*ithin minutes@ to a crescendo and a ma0imum point. )hey may occur a$ainst a $eneral +ac/$round of autonomic an0iety or emer$e *ith no symptomatic precursors. An attac/ may last up to an hour +ut dissipate $radually. 4oth free-floatin$ and pho+ic forms of an0iety may +e characteri%ed +y panic attac/s ?see item %7!&&@ and multiple ratin$s are then re=uired. Severity is rated in terms of fre=uency. Differentiation fro3 ot0er 123-to31/
Sudden onsets chiefly *ith palpitations should raise the possi+ility of a paro0ysmal tachycardia. !ate for or$anic attri+ution if there is clearly only a physical cause of panics or if the attac/s end suddenly. ,f there is some possi+ility that physical factors do not entirely e0plain the symptom& rate its presence conservatively +ut consider the ratin$ of or$anic or physical attri+ution in %7!'" and %7!'# or Section 1 at item "$7!$' . An attac/ descri+ed +y ! as panic +ut lastin$ more than an hour may +e part of a more $eneral an0iety state. 8anic attac/s occurrin$ only as a direct result of psychotic e0periences are rated 3. %7!#" Endurin> a--re0en1ion of 0a?in> anot0er -ani atta@ )his item represents a special form of item $7!!"& *orry& +ut the concern and the
preoccupation is focused specifically on fear of developin$ a further attac/ or attac/s in a respondent *ho has already had such attac/s previously. 9se Scale ,. %7!## Ation to -re?ent or to end -ani atta@
8anic attac/s may lead to an escape response. 8eople *ho cannot $et their +reath may rush outside for air. )hose *ith a$orapho+ia may leave the +us they are travelin$ on& or rush out of a supermar/et. )hose *ho are an0ious *hen left on their o*n& or *ho have a pho+ia of spiders and find a lar$e one in the /itchen& may phone their spouse or a friend& or $o into a nei$h+ors house. )a/in$ an0iolytic medication to try to a+ort an attac/ and
not ;ust prevent it *ould also +e rated here. %7!#$ Free6floatin> an.iet2
)he essential re=uirement for ratin$ this item is clear-cut an0iety& accompanied +y an affect of fear or apprehension. )he respondent may descri+e this in terms of nervous tension ?item $7!!#@& *hich can +e re$arded as the co$nitive component of autonomic an0iety. 4ut since it can occur *ithout autonomic symptoms& it should +e rated independently. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 3 8AN,C& ANQ,')"& AN# 8HO4,AS ,solated autonomic symptoms& such as occasional palpitations in the a+sence of the affect of an0iety& are not included in this symptom. Ho*ever& those afflicted are sometimes una+le to descri+e their affect clearly& even *hen there is a ran$e of an0iety or autonomic symptoms. Clinical ;ud$ement should +e used. )he an0iety should +e free-floatin$& that is& not e0clusively tied to some e0ternal situation. A common occasion is *hen affected people are tryin$ to $o off to sleep and& *ith their ear pressed into the pillo*& hear their heart +eatin$. A minor chan$e in rhythm may ma/e them thin/ their heart *ill stop. A su+;ective feelin$ of +ein$ una+le to ta/e a +reath properly is another common occurrence. Sometimes the an0iety is tri$$ered +y *orryin$ thou$hts& returnin$ *henever a particular topic intrudes into consciousness. An0iety tends to +e prolon$ed ?not meetin$ the criteria for panic& thou$h the t*o symptoms can occur alternately@ rather than fluctuatin$ +ut +rief episodes should +e included. Severity is rated accordin$ to intensity and fre=uency durin$ the relevant period. Differentiation fro3 ot0er 123-to31/ ,f the criteria for panic attac/s ? %7!#!@ are also met& a separate ratin$ should +e made.
,f an0iety reactions are confined to certain situations they should +e rated under situational an0iety& social pho+ia or specific pho+ia ?items %7!%'= %7!%*= %7!&#@. An0ious fore+odin$& as defined in symptom %7!#% +elo*& is a separate symptom& rated independently. #o not include an0iety appropriate to the situation& e.$. $oin$ into +attle& narro*ly avoidin$ a traffic accident& realistic fear of punishment& an0iety +efore or durin$ an e0amination. An0iety due to psychotic symptoms& e.$. that the su+;ect is +ein$ hunted and may +e /illed& should +e rated 3. %7!#% An.iou1 fore ;it0 autono3i 123-to31
)he su+;ect fears that somethin$ dreadful is $oin$ to happen. )he fore+odin$ is accompanied +y autonomic symptoms. ,t may occur in particularly concentrated form first thin$ in the mornin$& *hen those afflicted feel una+le to face the day ahead. )he sense of fore+odin$ is primary. )hose afflicted in this *ay cannot readily e0plain *hat they are afraid of& and any specific *orries appear& if at all& as a secondary ela+oration. Severity is rated accordin$ to intensity and fre=uency durin$ the period.
Differentiation fro3 ot0er 123-to31/
#o not include simple free-floatin$ an0iety ?item %7!#$@ unaccompanied +y fore+odin$& or appropriate an0iety concernin$ real *orries. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 8AN,C& ANQ,')"& AN# 8HO4,AS 37 #istin$uish from somatic depression& *hich is *orst early in the day and may involve rumination over ruination or other future disaster. )hen the affect and symptomatic conte0t is predominantly one of depression an0iety is secondary. Ho*ever& each SCAN item should +e rated on its merits& irrespective of +ac/$round dia$nostic ;ud$ements ?unless other*ise specified in the te0t@. ,f depression and an0iety are present to$ether& rate +oth& and also item '7!##. %7!#& Duration of free6floatin> an.iet2
)his item is included +ecause some nosolo$ies re=uire symptoms to have +een present for a specified len$th of time in order to =ualify for inclusion in a cate$ory. 'nterin$ the num+er of months provides enou$h information to meet several such rules. ,f the item is left +lan/& the computer accepts the default option ?::@ and no classification of $eneral an0iety can +e made. !aters& therefore& should al*ays +e sure to fill in all relevant course items. %7!#' De-er1onaliation or derealiation ;it0 an.iet2 See item $7!"# for a definition of depersonali%ation. )his may +e associated *ith
an0iety *ith autonomic symptoms. Occasionally a panic attac/ may terminate in a state of depersonali%ation. Only the con;unction of the t*o /inds of e0perience ?*hich may alternate@ is rated at item %7!#'. Differentiation fro3 ot0er 123-to31/
)his item is different from& +ut can co-e0ist *ith& items $7!"# and "'7!!' 6 "'7!!*. P,O5IAS GENERAL POINTS A5O+T P,O5IAS
8ho+ias are irrational fears of particular situations or o+;ects& e0posure to *hich& or thou$hts of *hich& produce autonomic symptoms that are not under conscious control and a tendency to avoid the stimulus. Some classification systems ?i.e. #S<@ do not re=uire autonomic symptoms to have +een present +ut do re=uire other symptoms of *orry& tension and apprehension& as in Section symptoms. )here is mar/ed distress due to avoidance or an0iety symptoms. Symptoms are restricted to the feared situation or to anticipation of the feared situation. %7!#( 6 %7!$# Situational -0o
)he full form of the symptom consists of an0iety *ith symptoms from the list of items %7!!$ 6 %7!"*& *hich is confined to certain situations or causes avoidance of these situations. A central element is fear of +ein$ alone& particularly amon$ stran$ers& ?often called a$orapho+ia@. '0amples are an0iety due to +ein$ alone in a confined or open space ?+uses& lifts& trains& cars& fields& s=uares& etc.@& or in cro*ds& or collapsin$ *hen no help is
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 35 8AN,C& ANQ,')"& AN# 8HO4,AS near. )hese fears are e0acer+ated +y a sense of +ein$ trapped and alleviated +y a sense of +ein$ supported. ,f the symptom is present *ith nervous tension ?item $7!!#@ *ithout a history of autonomic accompaniments& or non-autonomic an0iety& rate 1 ?partial@ *ith autonomic accompaniments the full symptom is rated 2. Differentiation fro3 ot0er 123-to31/
)*o types of situations are not included here +ut are rated separately. )he first is an0iety occurrin$ *hen ! is o+li$ed to interact *ith others ?items %7!$$ 6 %7!$'@. )he fear of cro*ds in a$orapho+ia is associated *ith a feelin$ of aloneness in an anonymous mass of people rather than the more personal fear in social pho+ias. )he second is an0iety due to very specific causes& such as fear of feathers& +irds& spiders& insects& cats& etc. ?items %7!$( 6 %7!%&@. )hese t*o /inds of symptoms may co-e0ist *ith situational an0iety ? %7!#( 6 %7!$#@ and then more than one ratin$ *ill +e necessary. Similarly& su+;ects may suffer from +oth free-floatin$ an0iety ?item %7!#$@ and situational an0iety& and +oth symptoms *ill then +e rated as present. %7!$$ 6 %7!$' Soial -0o
)he symptom consists of an0iety *ith symptoms from the list of items %7!!$ 6 %7!"*& *hich is confined to certain situations or causes their avoidance. )he central feature is an0iety under the scrutiny of others. ,n the e0treme form& ! may +e una+le to eat& drin/& or *rite in pu+lic& or ;oin any social $roup. ,n milder cases& ! may feel uneasy spea/in$ to a $roup of friends& for e0ample at a social $atherin$& *orry a+out +lushin$ or trem+lin$ in pu+lic& or feel apprehensive a+out approachin$ stran$ers to as/ for directions. ear of spea/in$ on the phone may +e a relatively isolated symptom or a part of a more severe distur+ance. ,f the symptom is present *ith nervous tension ?item $7!!#@ *ithout a history of autonomic accompaniments& or non-autonomic an0iety& rate 1 ?partial@ *ith autonomic accompaniments the full form of the symptom is rated 2. Differentiation fro3 ot0er 123-to31/
)hose *ho merely feel an0ious due to lac/ of practice in spea/in$ formally in front of an audience should not +e rated here. Other situational an0iety or specific pho+ias ?items %7!#( 6 %7!$#& %7!$( 6 %7!%&@ may co-e0ist& +ut it is important to differentiate this particular symptom since it often occurs alone. !ate fear of eatin$ in pu+lic only *hen this is due to fear of scrutiny +y others& not *hen it is due purely to the fear of eatin$ as it sometimes is in anore0ia nervosa. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 8AN,C& ANQ,')"& AN# 8HO4,AS 3( %7!$( 6 %7!%& S-eifi B1i3-le -0o
)he symptom consists of an0iety *ith symptoms from the list of items %7!!$ 6 %7!"*& *hich is confined to certain specific situations or o+;ects& or cause their avoidance. )hese include mice& insects& sna/es& cats& feathers& +irds& etc.& as detailed in items %7!$( 6 %7!%&. )he an0iety may $enerali%e - e.$. the su+;ect may +e una+le to leave the house for fear of meetin$ a cat. )his should still +e rated under this item. ,f the symptom is present *ith nervous tension ?item $7!!#@ *ithout a history of autonomic accompaniments& or non-autonomic an0iety& rate 1 ?partial@ *ith autonomic accompaniments the full form of the symptom is rated 2. Differentiation fro3 ot0er 123-to31/ ree-floatin$ an0iety ?item %7!#$@ may also +e present& in *hich case it is rated in
addition. )he fear of contractin$ disease& %7!%%& should +e distin$uished ?a@ from the delusional conviction of havin$ an illness ?items #7!)'= "*7!#(= "*7!#)@ ?+@ from dysmorphopho+ia ?item "'7!"" @ and delusions a+out appearance ?item "'7!"#@ ?c@ from delusional e0planations of somatic hallucinations ?e.$. items "(7!#)= "(7!#*@ ?d@ from o+sessional actions associated *ith cleanliness and fears of contamination ?item &7!!&@. ,t can +e difficult to distin$uish +et*een a pho+ia& an o+session and a delusion if !s description is not clear. !efer to the definitions of items cited and al*ays use the ratin$ of 5 if clinical ;ud$ement remains uncertain after ade=uate e0amination. %7!%( A?oidane of 3o1t 1e?ere an.iet2 -ro?o@in> 1ituation %7!&! A?oidane of 3o1t 1e?ere an.iet2 -ro?o@in> 1oial 1ituation %7!&$ A?oidane of 3o1t 1e?ere an.iet2 -ro?o@in> 1-eifi 1ti3ulu1
8ro+e for efforts or actions to avoid the most severe situationalE socialE specific pho+ias. )he an0iety induced +y the three types of situation varies from mild to intense. )he more severe it is& the more respondents are li/ely to try to avoid the provo/in$ stimuli. )hese items allo* a ratin$ of de$ree of overall +ehavioral avoidance and the distress and pain that this causes. )a/e into account the specific cultural settin$. !ate even if nervous tension ?item $7!!#@ *ithout a history of autonomic accompaniments& or an0iety *ithout autonomic accompaniments are descri+ed. 9se Scale ,. %7!%) Interferene ;it0 ati?itie1 due to 3o1t 1e?ere 1ituational fear %7!&" Interferene ;it0 ati?itie1 due to 3o1t 1e?ere 1oial fear %7!&% Interferene ;it0 ati?itie1 due to 3o1t 1e?ere 1-eifi fear
)hese items refer to the interference *ith normal everyday activities& *or/ and duties. %7!&& Relation of -ani1 to -0o
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 : 8AN,C& ANQ,')"& AN# 8HO4,AS %7!&' A>e at fir1t on1et of -ani1 or -0oan after an e-i1ode of 10io-0renia %7!&) P0oan after e-i1ode of 3aor affeti?e di1order
)hese four course items should al*ays +e completed if any part of Section 6 is used. 9se all the information availa+le& from the respondent& other informants& and case records&
to ma/e clinical ;ud$ements. ,f necessary& enter appro0imate a$e ?say& *ithin 3 years or so@& since this is more useful than leavin$ the +o0 +lan/. %7!&* Ti3in> of PERIOD1 of Setion % 123-to31
,t is important to ma/e a record here if the dates of symptoms in the Section are clearly different from those already recorded for 8S or !' E 4 in Section 1. or e0ample& a respondent *ho has recently developed a depressive episode may also have had positive items in this section that +e$an many years previously& possi+ly durin$ childhood or adolescence. or a short episode of symptoms it is necessary to record onset in days so that data is availa+le to determine if duration meets dia$nostic criteria. %7!'! Interferene ;it0 ati?itie1 due to -ani and autono3i 123-to31
9se interference scale as a+ove. %7!'" Or>ani au1e of an.iet2 123-to31 in Setion %
!atin$ of phenomenolo$y should in $eneral +e made *ithout consideration of etiolo$y. )he etiolo$y option allo*s individual items to +e separately lin/ed to an etiolo$ical attri+ution. )his item allo*s a more $eneral ratin$ of Setion %. Section 1 ?item "$7!$' @ also allo*s a simple ratin$ of *hether an or$anic cause is present& *hether or not it can +e specified in terms of an ,C#-1: class. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 8AN,C& ANQ,')"& AN# 8HO4,AS 1 %7!'# Identif2 or>ani au1e of Setion % 123-to31
Several or$anic conditions ?for e0ample& hyper- and hypothyroidism& pheochromocytoma and hypo$lycemia@& are /no*n to +e accompanied +y symptoms of an0iety. )he letter identifyin$ the ,C#-1: chapter& and up to three di$its& should +e entered here andEor in Section 1. A list is provided in the Appendi0. 8sychoactive su+stances rated in Sections 11 and 12& such as alcohol& cocaine& amphetamines and sedatives& can cause an0iety symptoms as to0ic or as *ithdra*al effects. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 2 O4S'SS,ONA S"<8)O
)he term o+session is used& for convenience& to cover compulsions as *ell. )he central feature of the su+;ective component of these symptoms is that they are e0perienced as occurrin$ a$ainst conscious resistance i.e.& they are intrusive and e$o dystonic. ,n the case of compulsions& this is accompanied +y e0pression in +ehavior. After a very lon$ time the e0perience of conscious resistance may +e$in to lose its force if ! ha+itually yields to the impulse - +ut the nature of the symptoms is +y then =uite o+vious. )hey are reco$ni%ed as +ein$ part of the respondents o*n thou$hts& and have an unpleasant repetitive =uality. ,f some elements of the symptom are missin$ - for instance& ha+itual tidiness *ithout a sense of compulsion - and there has +een no onset& consider the possi+ility that this is a life lon$ trait and part of the respondents personality. ,f
)he criteria $iven a+ove apply to all Section 3 phenomena. ear of contractin$ disease ?item %7!%%@ should +e distin$uished from an o+sessional preoccupation *ith contamination from $erms and the accompanyin$ compulsions. Hypochondriacal delusions ?items #7!)'= "*7!#(= "*7!#)@ carry no su+;ective e0perience of resistance. )ouretteRs Syndrome should +e rated as or$anicP attri+ution& +ut only if the e0aminer is certain that o+sessional phenomena cannot +e differentiated ?+oth forms of disorder e0istin$ to$ether should +e considered@. )he symptom must also +e differentiated from *orry *hich is not reco$ni%ed +y the su+;ect as intrusive even thou$h it may in fact +e unpleasant. Occasionally o+sessions have or develop features characteristic of delusions - one *oman +ecame delusionally convinced that there really *as a +a+y stuc/ do*n the toilet& *hereas +efore she had merely e0perienced o+sessional dou+t. ,n such cases the delusion should +e rated in preference& since the phenomenolo$y has chan$ed. ,n other cases& su+;ects may claim to have heard voices& as *ith a *oman *ho could not travel past a $raveyard +ecause she thou$ht that people had +een +uried alive and she felt impelled to ma/e sure that they had not - the voice confirmed her fears and in the process she moved from o+sessional dou+t to delusional conviction. )he differentiation from o+sessional traits can +e difficult. ,t is particularly important to +e sure that there has +een a clear onset follo*in$ a period *ith no symptoms& or a mar/ed e0acer+ation from a previous steady state. )he ratin$ scale omits a code of 1& +ecause of the necessity to ensure that the symptom really is present and not part of the normal ran$e of variation in traits such as orderliness& indecisiveness or carefulness. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 O4S'SS,ONA S"<8)O
4ecause of the e0tensive pro+in$ for symptoms in this Section& there is only one item a+ove the cut-off point. An entry of : indicates that the intervie*er is satisfied that no o+sessional or compulsive symptoms are present. &7!!# O<1e11ional 0e@in> and re-eatin>
)he chec/in$ or repetitive action is e0perienced as +ein$ carried out a$ainst conscious resistance. Such respondents are impelled to chec/ li$ht s*itches or $as taps many times ?not ;ust t*o or three times@& to touch or count thin$s& or to repeat the same action over and over a$ain. Sometimes the repetition has a ritual =uality desi$ned to control the feared situation in a superstitious *ay. !espondents /no* that the compulsion comes from *ithin themselves. &7!!$ O<1e11ional ation1 a11oiated ;it0 e.e11i?e orderline11
)hose afflicted are not merely tidy their tidiness is associated *ith a precise arran$ement or orderin$ of o+;ects - for e0ample& currency notes must +e the ri$ht *ay
round in the *allet ;ac/ets must face the same *ay in the *ardro+e actions have to follo* a ri$id se=uence& for instance& in preparin$ for sleep. ,f such compulsions are not o+eyed& there is a stron$ sense of unease& an0iety& irrita+ility or distress. At the same time& it is reco$ni%ed that these are internal compulsions. ,nclude eatin$ and coo/in$ rituals. &7!!% O<1e11ional t0ou>0t1 of 0ar3 or aident1
)hese ideas enter the mind a$ainst conscious resistance. !espondents are impelled to thin/ of certain ?usually unpleasant and distressin$@ ideas or ima$es& such as /nives or o+scenities. )hey may& for e0ample& have the ur$e to plun$e /nives into people *ho are *ith them& or to harm them in other *ays. )hey reco$ni%e this impulse as emer$in$ from *ithin themselves& +ut are distressed +ecause the thou$hts are at variance *ith ho* they normally vie* themselves. One mother had the repetitive thou$ht a+out her much loved ne* +a+y , *ish she *ere dead. Such thou$hts may +e associated *ith controllin$ compulsions or rituals& e.$. hidin$ /nives a*ay& thin/in$ three $ood thou$hts in a ro*& etc. ,t may +e appropriate to rate item &7!"! in addition. 4ecause the thou$hts are usually unaccepta+le to respondents& they may sometimes descri+e them as alien. 4y this they mean alien to their personal vie*s and attitudes. urther =uestionin$ *ill elicit the ac/no*led$ment that& ho*ever distasteful& they do not lac/ the sense of possession over their thou$hts. )he item can thus +e distin$uished from thou$ht insertion ?item ")7!!'@. &7!!& O<1e11ional ation1 a11oiated ;it0 leanline11
)he preoccupation *ith contamination and the associated rituals to prevent it occurrin$& such as e0cessive hand *ashin$& are e0perienced a$ainst conscious resistance. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 6 O4S'SS,ONA S"<8)O1 of ino3-letion
)hose affected e0perience repetitive and intrusive thou$hts a$ainst conscious resistance. )hese are often to do *ith an attempt at findin$ the ans*er to some pro+lem or $ettin$ some a+struse su+;ect clear in their minds. )hey may have to convince themselves that they have remem+ered every detail of a particular event. )hey may have to ruminate endlessly and inconclusively a+out some philosophical theory. Sometimes they may have to rehearse in their mind the details of a tas/ they cannot convince themselves they have completed. ,f a $ood description of such difficulties is spontaneously provided +y !& rate ?2@. At its most severe& the processes of thou$ht and speech are va$ue& repetitive& tortuous and pointless& +ut must +e continued nevertheless. A speech disorder that clearly reveals the underlyin$ phenomenon should +e rated as ?@. Differentiation fro3 ot0er 123-to31/
)his disorder& *hen chronic and *ithout su+;ective resistance or apparent distress& should +e distin$uished from drivelin$ or ram+lin$ speech ?item #%7!"(@& +y the fact that it develops from characteristic o+sessional +e$innin$s. &7!!( Fadin> of on1iou1 re1i1tane to o<1e11ional 123-to31
)he typical o+sessional e0perience involves ideas that intrude a$ainst conscious& and often desperate& attempts to e0clude them. )his is one of the /ey elements in reco$ni%in$ the nature of the symptom. Ho*ever& after years of stru$$le& the resistance may +e$in to fade and even disappear entirely& althou$h respondents seldom for$et the stren$th of their initial reaction. )his item is included to record such fadin$ and to allo* a classification even if it has occurred. &7!!) Relation of an.iet2 to o<1e11ional 123-to31 &7!!* Relation of de-re11i?e to o<1e11ional 123-to31 &7!"! Relation of o<1e11ion1 to o3-ul1ion1 &7!"" In1i>0t for o<1e11ional 123-to31
)hose affected +y repetitive and unpleasant thou$hts& ideas and ima$es and compulsions usually ac/no*led$e that these ori$inate in their mind and are not imposed +y outside persons or influences. )heir efforts to resist them are unsuccessful to a varyin$ e0tent. )hose affected also ac/no*led$e that the o+sessions and compulsions are WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 O4S'SS,ONA S"<8)O
)he o+sessional thou$hts& ideas or ima$es may +e the result of other mental disorders such as mood disorders& hypochondriasis or schi%ophrenia and related disorders. !ate here the e0tent to *hich content of o+sessional symptoms are limited to another disorder. &7!"$ A>e at fir1t on1et of o<1e11ional 123-to31 )he course ?&7!!)= &7!!*= &7!"# and &7!"$ items should al*ays +e completed if any
part of Section 3 is used. 9se all the information availa+le& from the respondent& other informants& and case records& to ma/e clinical ;ud$ements. &7!"% Ti3in> of PERIOD1 of o<1e11ional 123-to31
,t is important to ma/e a record here if the dates of symptoms in the Section are clearly different from those already recorded for 8S or !' E 4 in Section 1. or e0ample& a respondent *ho has recently developed a depressive episode may also have had positive items in this section that +e$an many years previously& possi+ly durin$ childhood or adolescence. or a short episode of symptoms it is necessary to record onset in days so that data is availa+le to determine if duration meets dia$nostic criteria. &7!"& Interferene ;it0 ati?itie1 due to Setion & 123-to31
)he o+sessions or compulsions usually cause varyin$ de$rees of distress and interference *ith the respondents social or individual functionin$ and everyday activities.
!ate the de$ree to *hich Section 3 symptoms cause interference *ith daily activities usin$ the Scale provided. &7!"' Or>ani au1e of o<1e11ional 123-to31 &7!"( Identif2 or>ani au1e of o<1e11ional 12-3to31
!atin$ of phenomenolo$y should in $eneral +e made *ithout consideration of etiolo$y. )he etiolo$y option allo*s individual items to +e separately rated for an etiolo$ical attri+ution. At the syndromal or section level a ratin$ of *hether an Ror$anicR cause is present& *hether or not it can +e specified in terms of an ,C#-1: class can +e made here andEor at item "$7!"( in Section 1. !ules for ma/in$ such attri+utions of cause can +e found in the te0t and $lossary& Section 1. )ouretteRs syndrome may +e associated *ith o+sessional symptoms& in *hich case it can +e entered here. )he letter identifyin$ any ,C#-1: chapter& and up to three di$its ?see Appendi0@& should +e entered also in Section 1. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 #'8!'SS'#
,n $eneral symptoms of affective disorder have a clear-cut onset. Ho*ever& if duration is very lon$standin$& there are opportunities to record the relevant dates in this Section. '7!!" De-re11ed 3ood
#epressed mood may +e e0pressed in a num+er of *ays - sadness& misery& lo* spirits& ina+ility to en;oy anythin$& $loom& de;ection& feelin$ +lue. )here are innumera+le local variants& *ith *hich e0aminers should +e familiar. #epression may sometimes +e e0pressed as apathy +ut this should +e e0cluded from the present ratin$ unless there is $ood evidence& for e0ample if it is a development from fran/ depression. #epressive apathy may +e included in the ratin$ of mas/ed depression ?item '7!!#@ or o+served depression ?item #$7!!"@. )earfulness& *hich should +e rated separately ?item '7!!$@& is a clue to severity& althou$h it is neither sufficient nor necessary ?the deepest depression may +e a fro%en misery *hich is +eyond tears@. Another criterion of severity is loss of reactivity ?'7!!)@ moderate forms of depression tend to come and $o more *ith circumstances than severe forms. Occasional sadness is part of normal human e0perience. ,t +ecomes patholo$ical *hen it is persistent& pervasive& unresponsive& painful and out of proportion. ,t should then +e rated as present even if there has +een an apparently sufficient cause. Criteria for ratin> B"
B#
)he intensity is moderate most of the time. )here may sometimes +e deep depression for +rief periods. Occasional episodes of cryin$ may occur& often +ecause of some upsettin$ incident. !espondents cannot s*itch attention voluntarily to non-depressin$
topics& +ut it can +e directed temporarily to pleasanter matters ?for e0ample& +y *or/in$ hard& +y the conversation of others& +y chance happenin$s of an interestin$ /ind@. ,f a ma;or loss such as a +ereavement has occurred the severity& duration or intensity should +e unusual under the circumstances durin$ the 8'!,O#. )he e0aminer should consider ho* many people *ould feel this *ay under these circumstances and rate 2 if the mood is unusual& +ut rate 1 if *ithin the $enerally e0pected ran$e. )he depression remains in the +ac/$round and tends to come floodin$ +ac/. ,n most cases& depression of this de$ree *ould last 16 days or more. #uration of depressed mood is rated separately in item '7!!&. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 #'8!'SS'# B$
Severe depression most of the time *ithout variation unless it is re$ularly diurnal. )here are episodes of cryin$ for no reason at all& unless there is apathy or approachin$ stupor. )he mind is almost totally occupied +y depressin$ topics it is very difficult for the su+;ect to $ive attention to anythin$ else& e.$. cannot +e distracted +y *or/in$ harder& *atchin$ somethin$ interestin$ on the television& or other peoples conversation. #epression of this de$ree usually lasts 16 days or more. Differentiation fro3 ot0er 123-to31/
Other forms of unpleasant affect ?e.$. *orryin$& nervous tension& or an0ious fore+odin$@ should +e rated separately ?see definitions for items $7!!"= $7!!# and %7!#% respectively@. #epression may *ell +e present at the same time. ,f present on and off for t*o years or more& consider ratin$ also the chec/list on dysthymia. '7!!# Ma1@ed de-re11ion
)his item is included to provide for circumstances *hen respondents cannot +e rated as overtly depressed ?or not at an appropriate level of severity@ +ut the intervie*er considers that the depression is mas/ed. )he possi+ilities are ?a@ Another mood& such as irrita+ility& in *hich case do not rate here +ut at item "!7!!# ?+@ Apparent indifference of mood due to a loss of the capacity to feel sadness or other emotions that have +een present& ?see item '7!!(@ ?c@ #ifficulty *ith introspection& +ecause of co$nitive pro+lems or lan$ua$e difficulties ?ale0ithymi@ ?d@ 'ducational pro+lems ?e@ ocal cultural tendency to manifest depression in forms other than mood& e.$. in somatic symptoms ?f@ #enial. ?$@
)ears as an immediate response to an upsettin$ event are not patholo$ical. Occasional +ut overt *eepin$ over a period of days should +e rated 2& even in the conte0t of an understanda+le provocation& if the criteria for non-specific symptoms stated at the head of Section & a+ove& are met. on$ periods of *eepin$& *ithout any control& are rated . WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 5 #'8!'SS'#
!espondents *ith this symptom have lost their capacity for en;oyment& the a+ility to ta/e pleasure in activities that they normally en;oy. )hey are also no lon$er capa+le of pleasura+le anticipation. ,f present on and off for t*o years or more& consider ratin$ the chec/list on dysthymia. '7!!& Duration of de-re11ed 3ood or an0edonia
)his item is self e0planatory. ,t is essential for certain classification systems. #ifferentiate from '7!#' ?dates of the *hole ran$e of depressive symptoms@. C+T6OFF POINT
Al*ays continue +elo* the cut-off point if there is any reason to suppose that any of the remainin$ Section items are present. !emem+er that some of them could +e present in the a+sence of depressed mood. ,f Section symptoms are present& e0tra care should +e ta/en to chec/ for Section 7 and 5 symptoms. '7!!' Lo11 of 0o-e for t0e future
)he afflicted persons vie* of the future is +lea/ and *ithout comfort& irrespective of the true circumstances. A ;ud$ement on clinical severity turns on the e0tent to *hich there is an attempt to cope& or islands of some hope ?ratin$ of 2@& or *hether personal and social affairs are ne$lected +ecause of hopelessness a+out the future. Hopelessness is a common accompaniment and apparent cause of suicidal thou$hts and +ehavior +ut these should +e rated separately. Note that hopelessness is not necessarily accompanied +y depression. Differentiation fro3 ot0er 123-to31/
#elusions *ith content centered on ruination& disease and death may or may not +e accompanied +y a feelin$ of hopelessness. ,nsofar as it is possi+le& the feelin$ should +e rated separately from the content. 9se a ratin$ of 3 if the separation cannot +e made. ,f present on and off for t*o years or more& consider ratin$ the chec/list on dysthymia. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 #'8!'SS'#
'7!!( Feelin> of lo11 of feelin>
!espondents must descri+e a definite lo11 of the a+ility to feel emotion& compared *ith their normal state. )he description in 'u$en 4leulers te0t+oo/ is )he loss of feelin$ is felt& the num+ness perceived& the lifelessness e0perienced. !espondents can remem+er a time *hen they did have the capacity for feelin$& *hich mi$ht have +een months or years earlier. )he symptom need not have +e$un durin$ the period +ein$ rated. An e0ample is an elderly depressed *oman *ho can no lon$er feel the love she had ?and says she still has@ for her $randchildren. )he ina+ility to feel this love causes severe distress. )he symptom is usually associated *ith depressed mood& particularly if there is chronic depressive apathy. ,t can also +e associated *ith irrita+ility and *ith affects such as an0iety. !espondents may also say they are depressed& meanin$ that an earlier mood of sadness has +een replaced +y num+ness or that the t*o symptoms are present to$ether. Differentiation fro3 ot0er 123-to31/
)his is a su+;ective complaint and should not +e confused *ith +luntin$ of affect ?item #$7!"#@. )he symptom is not delusional& and it is not lac/ of insi$ht. )here is no e=uivalent trait since the symptom must have an onset. '7!!) Lo11 of reati?it2
)he ratin$ depends solely on the unchan$in$ nature of the depressed mood. !ate if depression is pervasively present& even if there is some variation in intensity *ith circumstances. See Scale in de-re11ion
)he respondent states une=uivocally that depression is *orst durin$ the early part of the day and then improves. )his is rated ?1@. Characteristically& su+;ects *a/e early and then lie a*a/e feelin$ that they cannot $et up and face the day. )here may +e a mar/ed sense of speedin$ up as the day pro$resses& *ith a return even to normal mood +y evenin$. ,f depression is not particularly mar/ed in mornin$s& or is mar/ed +oth in the mornin$s and the evenin$s& rate ?:@. '7!"! Preou-ation ;it0 deat0 or ata1tro-0e
)his item is rated on the content of depressive preoccupations that fall short of delusional =uality. )his may involve physical dama$e& domestic upset& financial disaster& or illness that may happen to respondents& or to mem+ers of their families or friends. )hey reali%e the thou$hts ori$inate *ithin themselves& and can achieve some o+;ectivity concernin$ the real situation. Nevertheless& the ideas have a po*erful hold on the ima$ination. Where a +elief in the fact or certainty of specific disasters is held *ith unsha/a+le conviction& rate under item '7!"* "*7!#'. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 7: #'8!'SS'#
A rare and fleetin$ thou$ht a+out suicide is not rated here. 8ersistent intrusiveness or a more deli+erate consideration or plannin$ of possi+le techni=ues is rated ?1@. ,f a
suicidal act is actually made& includin$ a moderate de$ree of self in;ury& +ut there is dou+t as to *hether it *as really intended to result in the !espondents death& rate ?2@. Serious self-harm under similar circumstances is rated ?.@ A definite attempt& clearly intended to result in death is rated ?6@& irrespective of the de$ree of self harm that follo*ed. Seriousness of intent can +e ;ud$ed from !s /no*led$e of ho* lethal the method *as& attempts to avoid discovery and +ehavior indicatin$ a +elief that the attempt *ould +e successful e.$. a suicide note. Note that ratin$s of this item do not re=uire an assumption that depress ed mood *as the cause of the +ehavior. '7!"# Tediu3 ?itae
)he respondent states that life holds nothin$ of interest and that there appears no positive reason for continuin$ it. )he feelin$ lac/s the active& intrusive =uality of suicidal ideation& +ut there may +e a stron$ *ish& passively e0pressed& not to *a/e in the mornin$& to *elcome the idea of a fatal disease& and perhaps even see/ an accident. '7!"$ Pat0olo>ial >uilt
Overconcern *ith some action that most people *ould a$ree *as +lame*orthy is usually rated ?1@. ,t can +e $iven a hi$her ratin$& if it is painful& out of proportion and +eyond control. or a ratin$ of ?2@ patholo$ical $uilt can ta/e t*o forms. ,n one form& respondents +lame themselves too much for some peccadillo *hich most people *ould not ta/e very seriously. )hey reali%e that the $uilt is e0a$$erated or unduly prolon$ed& +ut cannot help feelin$ it all the same. )he second form of moderate patholo$ical $uilt may concern actions or deficiencies that have some +asis in fact. Ho*ever& respondents e0perience a sense of $uilt that is painful and e0cessive. !espondents are a*are ?perhaps *ith occasional lapses@ that the feelin$ is out of proportion to circumstances. !ate this condition ?2@& irrespective of fre=uency durin$ the relevant period. ,n the more intense form of the symptom& respondents $enerali%e the feelin$ of self-+lame to almost anythin$ that $oes *ron$ in their environment. )hey reali%e that the $uilt is e0a$$erated +ut cannot help feelin$ it all the same. !ate this condition ?@ irrespective of fre=uency durin$ the period. #o not include delusions of $uilt in *hich su+;ects may feel they have committed some terri+le crime or are to +lame for all the sins of the *orld& and have no insi$ht into the ori$ins of the symptom *ithin their o*n minds ?items '7!") "*7!#&@. '7!"% Guilt2 idea1 of referene
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 #'8!'SS'#
of some +lame*orthy action or attri+ute. A$ain they reali%e that this feelin$ ori$inates *ithin themselves +ut cannot help feelin$ it all the same. !ate this condition as ?@& irrespective of fre=uency durin$ the past month. ,f the su+;ect has actually committed some +lame*orthy act this may +e rated in the usual *ay& provided only that other people cannot /no* of it. ,f they do /no* of it& rate ?:@ or if in dou+t ?5@. Differentiation fro3 ot0er 123-to31/
#o not include delusions of $uilt ?items '7!") "*7!#&@ in *hich respondents thin/ they deserve punishment for some crime that they have committed. #o not include patholo$ical $uilt& not amountin$ to delusions& *hich is not pro;ected as an idea of reference ?item '7!"$@. Other differentiations are from dysmorphopho+ia ?item "'7!""@ and its delusional form ?item "'7!"#@& and social pho+ias ?particularly items %7!$& and %7!$'@. '7!"& Lo11 of 1elf6onfidene ;it0 ot0er -eo-le
Afflicted people lose confidence in their social s/ills and anticipate discomfort and failure in matters *hich depend upon confidence in social relationships. #o not ta/e into account confidence in mechanical or intellectual a+ilities. )he loss may +e caused +y the presence of other mental symptoms& such as an0iety& *hich are rated separately. Differentiation fro3 ot0er 123-to31/
,t is particularly important to rate the symptom only on the +asis of a definite lo11 of normal functionin$. 8oor self-confidence can occur as a life-lon$ trait and +e accompanied +y& and possi+ly cause& depression. Since this does not meet the criteria for a symptom it should +e rated a+sent& or uncertain ?5@. Other possi+ly confusin$ symptoms are ideas of reference ?item $7!"!@ social pho+ias ?particularly items %7!$&= %7!$'@ $uilty ideas of reference ?item '7!"%@ dysmorphopho+ia ?item "'7!"" @. )hese are all possi+le accompaniments or causes and should +e rated separately. ,f present on and off for t*o years or more& consider ratin$ the chec/list on dysthymia. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 72 #'8!'SS'#
,n the less intense form of the symptom& ! does not see/ company +ut does not refuse it *hen offered. ,n the more intense form& the su+;ect actively *ithdra*s and refuses company even *hen it is offered. !ate on a com+ination of severity and intensity. Differentiation fro3 ot0er 123-to31/
,f social *ithdra*al appear to +e a life-lon$ trait consider also the ratin$ of Hypersensitivity to ,nterpersonal re;ection ?item #(7!$% @. #ifferentiate also from social pho+ia and avoidance of social pho+ia ?items %7!$$ 6 %7!$' and %7!&!@ and from Suspiciousness ?item $7!""@. )he commonest accompanyin$ mental state is depression& *hich may +e a cause or a
conse=uence and should +e rated independently. '7!"( Lo11 of 1elf e1tee3
!espondents *ith this symptom say that they feel inferior to others& even& in the most intensive form of the symptom& *orthless. ,deas of self-depreciation are an e0a$$erated form of self-/no*led$e a+out part of the su+;ects o*n character& *hich $ives a false picture +ecause it is not counter-+alanced +y a reco$nition that most human +ein$s have similar faults. Self-depreciation implies a raisin$ of the standard applied to the su+;ect *ithout an e=uivalent raisin$ of the standard applied to others& or ta/in$ into account +alancin$ merits. )he commonest accompanyin$ mental state is depression& *hich may +e a cause or a conse=uence and should +e rated independently. Differentiation fro3 ot0er 123-to31/
#istin$uish from symptoms such as $uilt ?item '7!"$@& ideas of reference ?items $7!"!= '7!"%@ social pho+ias ?items %7!$&= %7!$'@& and depressive delusions of $uilt ?item '7!") "*7!#&@. ,f present on and off for t*o years or more& consider ratin$ the chec/list on dysthymia. PSYC,OTIC AFFECTI4E SYMPTOMS
)hese items are repeated in 8art ,, of SCAN at items "*7!#&= "*7!#'= "*7!#( and "(7!"!= "(7!"" respectively. )hey are defined there. ,f ratin$s are made in Section & the computer pro$ram allocates them to their e=uivalents in 8art ,,. ,f +oth sets of items are rated& the 8art ,, items are $iven preference. ,t should +e noted that other relevant psycholo$ical and +ehavioral a+normalities are rated only in 8art ,,& for e0ample& stupor WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 #'8!'SS'# uilt or ;ort0le11ne11 in onte.t of de-re11ion '7!"* Delu1ion1 of ata1tro-0e in onte.t of de-re11ion '7!#! ,2-o0ondriaal delu1ion1 in onte.t of de-re11ion '7!#" Con>ruene of auditor2 0alluination1 ;it0 affeti?e 1tate
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 76 #'8!'SS'#
,f the su+;ect suffers from +oth an0iety and depression& and +oth have +een rated as +ein$ present& try to decide *hich is primary. !espondents are =uite often clear a+out the ans*er ho*ever& the ;ud$ement must +e made +y the intervie*er on the +asis of all the availa+le information.
An0iety is primary *hen any depression appears to +e mainly e0plica+le in terms of the limitations placed on respondents +y their an0iety symptoms& or seems part of the an0iety process. )hus +ein$ una+le to leave home or travel or meet people& or +ein$ afraid that palpitations mean heart disease& may +e very distressin$. !espondents may feel that if the an0iety symptoms *ere not present the depression *ould vanish also. On the other hand& the an0iety mi$ht *ell remain even if the depression disappeared. )hese situations& or *hen lon$-standin$ an0iety provides a conte0t for intermittent and pro+a+ly derivative depression& are rated ?1@. At the other e0treme& the symptoms of an0iety may +e reactive to the depressive condition - particularly if an0iety ta/es the form of fears of catastrophe& fore+odin$s a+out illness or death& early mornin$ dread at havin$ to face the day& or a feelin$ that somethin$ a*ful is $oin$ to happen. ,n other cases the an0iety can +e seen as part of a depressive process. 'ven *hen there are autonomic accompaniments& these an0iety symptoms may +e seen =uite clearly as secondary to depression - they *ould disappear if the depression did& +ut the depression *ould not necessarily +e +etter if the an0iety disappeared. An0iety due to fear of mor+id or suicidal ideas is even more clearly secondary to depression. )hese conditions are rated ?@. ,n +et*een these t*o fairly strai$htfor*ard conditions& there are situations in *hich +oth an0iety and depression are present& +ut either they seem independent of each other or it is not possi+le to decide *hich one is primary. !ate +oth of these conditions ?2@. )here is a full definition of ratin$ levels in the 8S'1: te0t. )he item is not used in al$orithms +ut is useful for research into the relationship +et*een an0iety and depressive disorders. '7!#$ Relation of 1o3atofor3 to de-re11i?e 123-to31
)hese course items should al*ays +e completed if any part of Section is used. 9se all the information availa+le& from the respondent& other informants& and case records& to ma/e clinical ;ud$ements. '7!#% Relation of o<1e11ional to de-re11i?e 123-to31
)hese course items should al*ays +e completed if any part of Section is used. 9se all the information availa+le& from the respondent& other informants& and case records& to ma/e clinical ;ud$ements. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 #'8!'SS'# e at fir1t on1et of de-re11i?e 123-to31 '7!#' Ti3in> of PERIOD1 of Setion ' de-re11i?e 123-to31
,t is important to ma/e a record here of the dates of onset of symptoms in the Section. Confer *ith those already recorded for 8S or !' E 4 in Section 1. or a short episode of symptoms it is necessary to record duration in days so that data is availa+le to determine if duration meets dia$nostic criteria& e.$.& 16 days or lon$er. '7!#( Interferene ;it0 ati?itie1 due to de-re11ion
)his item relates to the a+ility to carry out normal activities and roles& *hich tends to
+e pro$ressively impaired as depression deepens. Some people are affected at relatively moderate levels of depression& others soldier on until there is a precipitate collapse of function. !ate actual performance& as indicated in the scale. '7!#) Or>ani au1e of de-re11i?e 123-to31
!atin$ of phenomenolo$y should in $eneral +e made *ithout consideration of etiolo$y. )he etiolo$y option allo*s individual items to +e separately rated for an etiolo$ical attri+ution. '7!#* Identif2 or>ani au1e of de-re11i?e 123-to31
!atin$ of *hether an or$anic cause is present& *hether or not it can +e specified in terms of an ,C#-1: class should +e considered and rated here andEor in Section 1 or usin$ the etiolo$y option for individual items. #ementia& endocrine or other physical disorders associated *ith depressive symptoms may +e recorded here and in Section 1. )he letter identifyin$ the ,C#-1: chapter& and up to three di$its& should +e entered. A list is provided in the Appendi0. ,ISTORY ITEMS '7!$! E-i1ode1 of 3aor affeti?e di1order '7!$" Per1onalit2 -rior to de-re11ion on1et '7!$# Se?erit2 of affeti?e e-i1ode1 '7!$$ T;o or 3ore de-re11i?e e-i1ode1 ;it0 reo?er2 '7!$% Re1-on1e to adeuate antide-re11i?e t0era-2
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 7 #'8!'SS'# t0e our1e
)hese course items should al*ays +e completed if any part of Section is used. 9se all the information availa+le& from the respondent& other informants& and case records& to ma/e clinical ;ud$ements. '7!$' Mi.ed e-i1ode1 durin> t0e our1e
A mi0ed episode is characteri%ed +y either a mi0ture or a rapid alternation of hypomanic or manic *ith depressive symptoms. #uration re=uired for #S<,> is one *ee/ and for ,C#-1: 2 *ee/s. ,f the current episode is mi0ed rate ?6@ or ?3@. '7!$( 6 '7!%$ Date1 of ' 3o1t reent e-i1ode1 of de-re11i?e di1order1
)his ratin$ is re=uired for the classification of ,C#-1: and #S< dia$noses of recurrent& seasonal and rapid cyclin$ su+types of depression. 'pisodes are demarcated either +y remission for at least 2 months or +y a s*itch to an episode of opposite polarity ?e.$. depressive episode to manic episode@. ,f clear-cut episodes of the same polarity have occurred *ith remissions shorter than the usual period ?defined in SCAN as 2 months@ their dates should still +e recorded as separate episodes. )he al$orithms *ill deal *ith these data su+se=uently& dependin$ on the classification rules +ein$ applied. #efinitions of onset and remission ?=uality of remissions "7!"*@ are as in Section 1 of the Glossary and should +e re-rated if necessary havin$ completed Sections and 1:. C,ECKLISTS
)his is an optional chec/list +ut it can +e rated usin$ information collected durin$ other parts of the intervie* and should therefore +e completed if there is any possi+ility that the disorder may +e present. )here is persistent despondency or $loom lastin$ at least 2 years& *ith +asic copin$ and periods of normal mood& +ut *ith a $eneral feelin$ of insufficiency. 8oor sleep& lo* ener$y& tedium vitae& and +roodin$ are common.
So far as the intervie* is concerned& similar recommendations apply to this Chec/list as to those for dysthymia and cyclothymia. )he disorder meets the symptom criteria for depressive episode and it is sensi+le& therefore& to complete the relevant main sections of 8art One. ,t is necessary to +ear the course criteria in mind *hen conductin$ the intervie*. )here should +e a phase at least once a month durin$ the previous year& phases should usually last a fe* days only& and they should not occur only in association *ith the menstrual cycle. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 75 )H,NB,NG& CONC'N)!A),ON& 'N'!G" AN# ,N)'!'S)S ( T0in@in>= onentration= ener>2 and intere1t1 GENERAL POINTS A5O+T SECTION (
Symptoms in Section 7 are $rouped to$ether for convenience +ut it *ill often +e necessary to ta/e them out of order& for e0ample *hen ratin$ a depressive episode or dysthymia. Ho*ever& all can ?and in population surveys do@ occur *ithout +ein$ part of any specific mental or physical disorder. #epression is not the only disorder associated&
thou$h it is pro+a+ly the commonest. 8sychotic or co$nitive impairments are other prominent associations 8art ,, should al*ays +e rated if they are suspected. 4e particularly careful to eliminate any tendency to rate items present accordin$ to presuppositions as to the eventual dia$nosis. )his Section is concerned only *ith the e0tent of any loss of efficiency at carryin$ out the functions specified. ,tems must also +e rated accordin$ to the $eneral rule that distin$uishes +et*een S"<8)Oniti?e funtionin> )his item& li/e items #7!!" and $7!!%& provides a useful indication as to *hether to
use the cut-off& and also an opportunity to rate positive functionin$ independently of other items *here impaired functionin$ is recorded. Someone *ho is depressed& for e0ample& may nevertheless +e a+le& throu$h determined concentration& to e0ploit talents or s/ills efficiently. )his may also allo* attention to +e turned a*ay from painful su+;ective e0periences. As every*here in the SCAN schedules& intervie*ers are as/ed to rate each item accordin$ strictly to the definition& independently of any e0pectations derived from other ratin$s. )he item is rated follo*in$ $eneral pro+es concernin$ the functions covered. Note the unusual ratin$ scale. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 )H,NB,NG& CONC'N)!A),ON& 'N'!G" AN# ,N)'!'S)S 7( C+T6OFF POINT If Setion ' 123-to31 are -re1ent=
)hose affected complain that they cannot $ive full attention to matters that re=uire it& or not for as lon$ as is re=uired. )he e0perience is unpleasant& it is +eyond the su+;ects po*er to correct e0cept for very +rief intervals& and it is out of proportion to the difficulty of the pro+lems +ein$ considered. At its most intense& su+;ects cannot even read a fe* sentences in a ne*spaper& cannot *atch television& and cannot ta/e part in a conversation +ecause their mind *anders off. ,f su+;ects are definitely a*are of a reduction in their normal a+ility to concentrate&
+ut the effects are minimal& rate ?1@. ,f the symptom is causin$ moderate impairment in functionin$& e.$. an a+ility to ta/e in *ritten material for ade=uate periods or *ithout considera+le su+;ective effort& rate ?2@. )he severity criterion for ratin$ ?@ is that at *hich the su+;ect is virtually una+le to ta/e thin$s in at all. Differentiation fro3 ot0er 123-to31/
)here may +e several reasons for poor concentration& includin$ *orryin$& inefficiency of thin/in$& distracti+ility& an0iety& delusions& etc. )he ratin$ should +e made on the +asis of *hether the symptom is present& not on *hat its cause is. ,f a respondent has thou$ht insertion& commentary& *ithdra*al or +roadcast ?items ")7!!& 6 ")7!""@& or other psychotic e0periences or e0planations& or thou$ht or speech disorder& that ma/e the ratin$ difficult& rate ?3@. ,f present on and off for t*o years or more& consider ratin$ the chec/list on dysthymia. (7!!$ Su<eti?el2 ineffiient t0in@in>
)hose affected complain that they are una+le to thin/ clearly& that their +rain is *or/in$ less efficiently than their normal. )hey are una+le to reach decisions easily& even a+out simple matters& +ecause they cannot maintain the necessary elements of information in consciousness at the same time. ,t is thus the internal e=uivalent of loss of concentration. )hou$hts are muddled and tend to $o round and round in aimless circles. )his complaint is su+;ective& and may +e in contrast to the clear and efficient *ay in *hich su+;ects descri+e the symptom. Only the su+;ective complaint is rated. Ho*ever& the follo*in$ three criteria must al*ays apply the e0perience is unpleasant& it does not respond to su+;ects voluntary attempts to end it& and it is out of proportion to the difficulties of the pro+lems +ein$ considered. ,n order to meet the severity criterion for a ratin$ of ?@& there should either +e e0treme muddlin$ or mar/ed su+;ective slo*in$. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 5: )H,NB,NG& CONC'N)!A),ON& 'N'!G" AN# ,N)'!'S)S Differentiation fro3 ot0er 123-to31/
)here may +e several reasons for the symptom& includin$ *orryin$& inefficiency of thin/in$& distracti+ility& an0iety& poor concentration& etc. )he ratin$ should +e made on the +asis of *hether the symptom is present& not on *hat its cause is thou$ht to +e. ,f thou$ht insertion& commentary& *ithdra*al or +roadcast ?items ")7!!& 6 ")7!""@ are present& or other psychotic e0periences or e0planations& or thou$ht or speech disorder that ma/e the ratin$ difficult& rate ?3@. (7!!% Lo11 of intere1t1
)here is a definite recent diminution in the !espondents interests& either some interests have +een dropped& or the intensity of interest has decreased. 'veryone has interests of some sort& +ut the e0tent of any diminution must +e measured in the conte0t of the ran$e and depth of their usual activities. )a/e into account everyday vocational and domestic activities as *ell as leisure pursuits& /eepin$ *ell-informed& ta/in$ an interest in clothes& food and appearance& /eepin$ up to date *ith the ne*s& etc. ,nevita+ly& those
*ith the most intense and varied interests initially *ill have most room to lose interest and those *ho have never ta/en a $reat interest in thin$s *ill not have much to lose. An apprecia+le diminution in the $eneral level of interests is rated ?2@ almost complete loss is rated ?@. (7!!& Su<eti?e feelin> of retardation
)hose afflicted feel as thou$h they are movin$ mar/edly more slo*ly than usual& that they *al/ as thou$h they *ere older than their a$e. One descri+ed it as li/e *al/in$ in treacle. Speech may also seem to +e slo*ed. When very severe there is a su+;ective feelin$ of +ein$ hardly a+le to move or spea/ at all. O+;ective slo*ness is li/ely to +e o+served in such a case ?items ##7!!" 6 ##7!!*@. ,tem (7!!&& ho*ever& is concerned only *ith the su+;ectively descri+ed e0perience. ,f present on and off for t*o years or more& consider ratin$ the chec/list on dysthymia. (7!!' Lo11 of ener>2 Bdri?e
oss of ener$y is e0pressed in terms of feelin$ *ea/& floppy& of havin$ lost ones $et-up-and $o& ones vi$or. ,nitiatin$ a tas/& *hether physical or mental& seems difficult& even impossi+le. 'verythin$ seems too much trou+le. Differentiation fro3 ot0er 123-to31/
)he symptom may underlie others& such as tedium vitae ?item '7!"#@& loss of concentration or interests ?items (7!!# and (7!!%@& and a feelin$ of ina+ility to cope *ith everyday tas/s ?item (7!!(@& +ut these are defined more in terms of the accompanyin$ WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 )H,NB,NG& CONC'N)!A),ON& 'N'!G" AN# ,N)'!'S)S 51 content. Aner$ia is a relatively +asic symptom that does not depend on conte0t or content for its definition. ,f present on and off for t*o years or more& consider ratin$ the chec/list on dysthymia. (7!!( Feelin> of o?er;0el3ed <2 e?er2da2 ta1@1 )his may arise from lac/ of ener$y ?item (7!!'@ or as a conse=uence of apathy and su+;ective retardation ?item (7!!&@& often a$$ravated +y ne$ative self-attitudes. ,t consists
of a tendency to shy a*ay mentally from the prospect of any constructive activity. 'ven the contemplation of tas/s is painful& out of proportion to the mental and physical effort re=uired& and su+;ectively very difficult to overcome. ,f present on and off for t*o years or more& consider ratin$ the chec/list on dysthymia. (7!!) Ti3in> of PERIOD1 of Setion ( 123-to31
,t is important to ma/e a record here of the dates of onset of symptoms in the Section. Confer *ith those already recorded for 8S or !' E 4 in Section 1. or relatively short depressive episodes it is important to rate the period?s@ to the level of days in order to decide *hether the duration has +een 16 days or lon$er. (7!!* Interferene ;it0 ati?itie1 due to Setion ( 123-to31 (7!"! Or>ani au1e of Setion ( 123-to31
(7!"" Identif2 or>ani au1e of Setion ( 123-to31
WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 52 4O#," 9NC),ONS ) 5odil2 funtion1 GENERAL POINTS A5O+T ITEMS )7!!" 6 )7!!)= APPETITE AND WEIG,T
,f ! is in an episode of disorder it *ill usually +e necessary to rate Section 5 items for that period. ,t should +e /ept in mind that symptoms in Section 5 are $rouped to$ether for convenience. ,t *ill often +e necessary to ta/e them out of order& for e0ample *hen ratin$ an affective episode or eatin$ disorder. Some ratin$ scales specifically re=uire a decision as to *hether the symptom is associated *ith a depressive episode. Ho*ever& all can ?and in population surveys do@ occur *ithout +ein$ part of any specific mental or physical disorder. )he period to +e rated is specified for some items if ! is not in episode& rate the others for the past month ?8S chec/@. Wei$ht pro+lems related to physical disorders are rated usin$ the etiolo$y option. )7!!" 6 )7!!% Wei>0t= 0ei>0t and 0an>e 1ine adole1ene
)o o+tain a +aseline in youn$ patients or those *ho have +een persistently under or over*ei$ht& estimate postpu+ertal *ei$ht ?e.$. a$ed +efore 2:@. ,n cases of prepu+ertal-onset anore0ia nervosa& estimate chan$e from *ei$ht at the onset of the condition. )7!!& C0an>e in a--etite
ood and the thou$ht of food is not attractive even *hen a meal is due. ood has lost its savor - it is li/e eatin$ card+oard. ,t may ta/e a $reat effort to $o throu$h the motions of che*in$ and s*allo*in$. Wei$ht may not +e lost& if inta/e is maintained as an act of deli+erate policy. ,ncreased appetite& if almost daily should +e rated ?6&@ or ?3@ if for lon$er than 2 *ee/s. 8atients *ith anore0ia nervosa may or may not sho* poor appetite& re$ardless of their avoidance of food. )7!!' Lo11 of ;ei>0t )7!!( Gain of ;ei>0t
,n order for *ei$ht loss or $ain to +e rated ?1@ or ?2@& it must +e the result of a chan$e in appetite. ,f there is a possi+ility of Anore0ia or 4ulimia Nervosa use the information in Section (. !ate ma0imum *ei$ht chan$e durin$ period even if ori$inal appetite and *ei$ht has +een restored throu$h recovery. Wei$ht loss or $ain secondary to a physical condition should +e rated usin$ the etiolo$y option. WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 4O#," 9NC),ONS 5 )7!!) Wei>0t -ro
)his $eneral pro+e allo*s an e0ploration of the nature of any *ei$ht pro+lem that has not +een resolved so far. )7!!* 6 )7!"# Slee- -ro
,t should +e possi+le to rate these items +y o+tainin$ an overall account of sleepin$ patterns durin$ the period. !atin$s may +e difficult to ma/e in peop le *ho *or/ ni$hts& or varyin$ shifts li/e aircre*s. ,n such cases& ma/e the ratin$ only if there is clear evidence of distur+ance i.e. rate a departure from the usual diurnal rhythm rather than time of day. Sleep pro+lems related to physical disorders or e0ternal physical causes ?medication& psychoactive su+stance use etc.@ are rated usin$ the etiolo$y option. )7!"$ Middle in1o3nia
)his refers to the time of *a/in$ after the final period of sleep durin$ the ni$ht i.e. the su+;ect should not sleep a$ain after*ards. )a/e !s occupation into account i.e. rate a departure from the usual diurnal rhythm rather than time of day. Differentiation fro3 ot0er 123-to31/
,f the su+;ect does fall asleep a$ain after early *a/in$& rate middle insomnia ?item )7!"$@. )he ratin$ should +e made on the +asis of a chan$e from the usual pattern. Consider the possi+ility that some people are characteristically early risers. 'arly risin$ may derive from the demands of early *or/in$ hours and may persist for years after retirement or ;o+ chan$e. Wa/in$ early and refreshed in an episode of mania should not +e rated here& +ut at item "!7!"$. )7!"& Di1tur
,n the e0treme form there may +e day-ni$ht reversal - the su+;ect may potter a+out all ni$ht and sleep durin$ the day. 9sually ho*ever& it involves stayin$ a*a/e until *ell into the small hours follo*ed +y sleep& e.$. from 3 a.m. to 1 p.m. ,t is sometimes seen in unemployed people& and may +e a feature of social peculiarity in schi%ophrenia and WHO Schedules for Clinical Assessment in Neuropsychiatry - Glossary version 2.1 56 4O#," 9NC),ONS Asper$er syndrome. ,f an adaptation to permanent ni$ht shift *or/& it should +e e0cluded. )7!"' ,2-er1o3nia
Sleepin$ at least t*o hours lon$er than usual. )here must +e a definite chan$e from !s usual pattern. ,rresisti+le sleepiness is usually associated& as is a period of sleep drun/enness after *a/in$. A ratin$ of ?2@ means that the condition has lasted more or less daily for a month or more. Differentiation fro3 ot0er 123-to31/
