POSITIVE AND NEGATIVE SYNDROME SCALE (PANSS) RATING CRITERIA GENERAL RATING INSTRUCTIONS Data gathered from this assessment procedure are applied to the PANSS ratings. Each of the 30 items is accompanied by a specific definition as well as detailed anchoring criteria for all seven rating points. hese seven points represent increasing levels of psychopathology! as follows" #$ absent %$ minimal 3$ mild &$ moderate '$ moderate severe ($ severe )$ e*treme
+n assigning ratings! one first considers whether an item is at all present! as ,udging ,udging by its its definition. definition. +f the item item is absent! absent! it it is scored scored #! whereas whereas if it is present one one must determine determine its severity severity by reference reference to the the particular particular criteria criteria from the anchoring points. he highest applicable rating point is always assigned! even if the patient meets criteria for lower points as well. +n ,udging ,udging the level level of severity severity!! the the rater must must utilise utilise a holistic holistic perspective perspective in deciding which anchoring point best characterises the patient-s functioning and rate accordingly! whether or not all elements of the description are observed. he rating points of % to ) correspond to incremental levels of symptom severity" A rating of % /minimal denotes 1uestionable or subtle or suspected pathology! pathology! or it also may allude to to the e*treme e*treme end end of the normal range. A rating of 3 /mild is indicative of a symptom whose presence is clearly established but not pronounced and interferes little in day$to$ day functioning. A rating of & /moderate /moderate characterises a symptom which! though representing a serious problem! either occurs only occasionally or intrudes on daily life only to a moderate e*tent. A rating of ' /moderate /moderate severe indicates mar2ed manifestations that distinctly impact on one-s functioning but are not all$consuming and usually can be contained at will. A rating of ( /severe represents gross pathology that is present very fre1uently! proves highly disruptive to one-s life! and often calls for direct supervision. Eachmanual. this encircling item A psychopatholog psychop rating most supervision the is he rated appropriate or ofratings all atholog )in/e*treme ma,or consultation andare assistance number life whereby rendered refers functions! with following in to the onmany the manifestati ma the typically most definitions nifestations PANSS each areas. serious dimension. necessitating ons rating and drastically dras level criteria form tically of close overleaf provided interfere interfere byiin
PANSS
RATING
FORM
absent minimal mild mde!ate mde!ate se"e!e se"e!e e#t!eme
P# Delusions
$%&'*
P% onceptual disorganisation
$%&'*
P3 4allucinatory behaviour
$%&'*
P& E*citement
$%&'*
P' 5randiosity
$%&'*
P( Suspiciousness6persecution
$%&'*
P) 4ostility
$%&'*
N# 7lunted affect
$%&'*
N% Emotional withdrawal
$%&'*
N3 Poor rapport
$%&'*
N& Passive6apathetic social withdrawal
$%&'*
N' Difficulty in abstract thin2ing
$%&'*
N( 8ac2 of spontaneity 9 flow of conversation
$%&'*
N) Stereotyped thin2ing
$%&'*
5# Somatic concern
$%&'*
5% An*iety
$%&'*
53 5uilt feelings
$%&'*
5& ension
$%&'*
5' :annerisms 9 posturing
$%&'*
5( Depression
$%&'*
5) :otor retardation
$%&'*
5;
$%&'*
5=
$%&'*
5#0 Disorientation 5## Poor 5#% 5#3 5#& 5#' 5#( Active Preoccupation Disturbance Poor 8ac2attention impulse of social ,udgement of avoidance control volition 9 insight
$%&'* $%&'*
SCORING
INSTRUCTIONS
>f the 30 items included in the PANSS! ) constitute a Ne,ati"e S+ale
! and the remaining #( a
Psiti"e S+ale !)a Gene!al Ps-+./at.l,- S+ale .
he scores for these scales are arrived at by summation of ratings across component items. herefore! the potential ranges are ) to &= for the Positive and Negative Scales! and #( to ##% for the 5eneral Psychopathology Scale. +n addition to these measures! a omposite Scale is scored by subtracting the negative score from the positive score. his yields a bipolar inde* that ranges from ?&% to @&%! which is essentially a difference score reflecting the degree of predominance of one syndrome in relation to the other.
POSITIVE P$0
S CALE
(P)
DELUSIONS $ 7eliefs which are unfounded! unrealistic and idiosyncratic. 1asis 2! !atin, 3 hought content e*pressed in the interview and its influence on social relations and behaviour. $ % & ' *
P%0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ Presence of one or two delusions which are vague! uncrystallised and not tenaciously held. Delusions do not interfere with thin2ing! social relations or behaviour. $ Presence of either a 2aleidoscopic array of poorly formed! unstable delusions or a Mde!ate few well$formed delusions that occasionally interfere with thin2ing! social relations or behaviour. Mde!ate Se"e!e $ Presence of numerous well$formed delusions that are tenaciously held and occasionally interfere with thin2ing! social relations and behaviour. $ Presence of a stable set of delusions which are crystallised! possibly systematised! Se"e!e tenaciously held and clearly interfere with thin2ing! social relations and behaviour. E#t!eme $ Presence of a stable set of delusions which are either highly systematised or very numerous! and which dominate ma,or facets of the patient-s life. his fre1uently results in inappropriate and irresponsible action! which may even ,eopardise the safety of the patient or others.
CONCEPTUAL DISORGANISATION 3 process of thin2ing characterised by Disorganised disruption of goal$directed se1uencing! e.g. circumstantiality! loose tangentiality! gross illogicality or thought bloc2. associations! 1asis 2!ognitive$verbal !atin, 3 processes observed during the course of interview. $ % & ' *
P3.
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild$ hin2ing is circumstantial! tangential or paralogical. here is some difficulty in directing thoughts towards a goal! and some loosening of associations may be evidenced under pressure. $ Able to focus thoughts when communications are brief and structured! but Mde!ate becomes when dealing with more comple* communications or when loose or irrelevant under minimal pressure. $Se"e!e 5enerally has difficulty in organising thoughts! as evidenced by fre1uent Mde!ate irrelevancies! disconnectedness or loosening of associations even when not under pressure. Se"e!e $ hin2ing is seriously derailed and internally inconsistent! resulting in gross irrelevancies and disruption of thought processes! which occur almost constantly. E#t!eme$ houghts are disrupted to the point where the patient is incoherent. here is mar2ed loosening of associations! which result in total failure of communication! e.g. Cword salad or mutism.
4ALLUCINATORY erbal 1E4AVIOUR report or 3behaviour indicating perceptions which are not generated by e*ternal stimuli. hese may occur in the auditory! visual! olfactory or 1asis 2! !atin, 3 somatic erbal report realms. and physical manifestations during the course o
interview as well as reports of behaviour by primary care wor2ers or family. Absent $ Definition does not apply $ % & ' *
Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ >ne or two clearly formed but infre1uent hallucinations! or else a number of vague abnormal perceptions which do not result in distortions of thin2ing or behaviour. provo2e and these thin2ing tend e*periences verbal and to$ distort behaviour. and and thin2ing isbehavioural almost respond 4allucinations Patient and6or totally totreats responses! them disrupt preoccupied these emotionally arebehaviour. provided including asbut real with perceptions! and! acontinuously! Patient obedience hallucinations! rigid on delusional occasion! may and tohave command functioning which verbally athe delusional virtually asis Mde!ate $Patient 4allucinations occur fre1uently not and patient-s Mde!ate Se"e!e E#t!eme Se"e!e by thin2ing well. impeded interpretation hallucinations. fre1uent $ 4allucinations $ and 4allucinations dominate emotional behaviour of and occur and are areverbal only fre1uently! present affected responses almost may tocontinuously! ato involve minor them.e*tent. morecausing than one ma,or sensory disruption modality! o f
P'0
E5CITEMENT 3 4yperactivity as reflected in accelerated motor behaviour! heightened responsivity to stimuli! hypervigilance or e*cessive mood lability. 1asis 2!7ehavioural !atin, 3 manifestations during the course of interview as well as reports of behaviour by primary care wor2ers or family. $ % & ' *
P0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits $ ends to be slightly agitated! hypervigilant or mildly overaroused throughout the Mild interview! butepisodes of e*citement or mar2ed mood lability. Speech may be without distinct slightly$ Agitation pressured.or overarousal is clearly evident throughout the interview! affecting Mde!ate speech and general mobility! or episodic outbursts occur sporadically. $ Significant Mde!ate Se"e!e hyperactivity or fre1uent outbursts of motor activity are observed! ma2ing it difficult for the patient to sit still for longer than several minutes at any given Se"e!etime. $ :ar2ed e*citement dominates the interview! delimits attention! and to some e*tent affects personal functions such as eating or sleeping. E#t!eme $ mar2ed e*citement seriously interferes in eating and sleeping and ma2es interpersonal interactions virtually impossible. Acceleration of speech and motor activity may result in incoherence and e*haustion.
GRANDIOSITY 3 E*aggerated self$opinion and unrealistic convictions of superiority! delusionsincluding of e*traordinary abilities! wealth! 2nowledge! fame! power and moral righteousness. 1asis 2! !atin, 3 hought content e*pressed in the interview and its influence on
behaviour. $ % & ' *
P0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild$ Some e*pansiveness or boastfulness is evident! but without clear$cut grandiose delusions. $ Feels distinctly and unrealistically superior to others. Some poorly formed Mde!ate delusions about special status or abilities may be present but are not acted upon. Mde!ate Se"e!e $ lear$cut delusions concerning remar2able abilities! status or power are e*pressed and influence attitude but not behaviour. $ lear$cut delusions of remar2able superiority involving more than one parameter Se"e!e /wealth! fame! etc are e*pressed! notably influence interactions and may be 2nowledge! acted upon. $ hin2ing! interactions and behaviour are dominated by multiple delusions o E#t!eme ability!amaGing wealth! 2nowledge! fame! power and6or moral stature! which may ta2e on a biGarre 1uality.
SUSPICIOUSNESS 6PERSECUTION 3 or e*aggerated ideas of persecution! as
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits $ Presents a guarded or even openly distrustful attitude! but thoughts! interactions Mild behaviour minimally persecutory there interpersonal $ and Distrustfulness is no are evidence delusions! relations! is ofclearly but persecutory oraffected. else these evident there do delusions. not are and seem clear$cut intrudes to Alternatively! affect persecutory on the theinterview patient-s there delusions may attitude and6or be thatbehaviour! or have Mde!ate Se"e!e E but t $on Se"e!e indication interpersonal impact limited significantly thin2ing! lear$cut social $interpersonal of Ainterfere loosely relations. networ2 $relations Patient pervasive formed inofrelations shows interpersonal and systematised delusions behaviour. mar2ed and behaviour. relations. of persecutory distrustfulness! persecution delusions which leading may dominates tobe ma,or systematised the disruption patient-s and o
P*0
4OSTILITY erbal3 and nonverbal e*pressions of anger and resentment! including sarcasm! passive$aggressive behaviour! verbal abuse and assualtiveness. 1asis 2! !atin, 7 +nterpersonal behaviour observed during the interview and reports
by primary care wor2ers or family. $ % & '
*
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ +ndirect or restrained communication of anger! such as sarcasm! disrespect! hostile e*pressions and occasional irritability. $ Presents an overtly hostile attitude! showing fre1uent irritability and direct Mde!ate e*pression of anger or resentment. Mde!ate Se"e!eis highly irritable and occasionally verbally abusive or threatening. $ Patient Se"e!e $
N EGATIVE N$0
SCALE (N)
1LUNTED AFFECT 3 Diminished emotional responsiveness as characterised by reduction in facial e*pression! modulation of feelings and communicative 1asis 2! !atin,gestures. 3 >bservation of physical manifestations of affective tone and
emotional responsiveness during the course of the interview. $ % & '
*
N%0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ hanges in facial e*pression and communicative gestures seem to be stilted! forced! artificial or lac2ing in modulation. $ Heduced range of facial e*pression and few e*pressive gestures result in a dull Mde!ate appearance Mde!ate Se"e!e $ Affect is generally Iflat- with only occasional changes in facial e*pression and a paucity of communicative gestures. $ :ar2ed flatness and deficiency of emotions e*hibited most of the time. here Se"e!e may be unmodulated e*treme affective discharges! such as e*citement! rage or inappropriate uncontrolled laughter. E#t!eme ? hanges in facial e*pression and evidence of communicative gestures are virtually absent. Patient seems constantly to show a barren or Iwooden- e*pression.
EMOTIONAL 8IT4DRA8AL 3 interest in! involvement with! and affective 8ac2 of commitment to life-s events. 1asis 2! !atin, 3 of functioning from primary care wor2ers or family and Heports observation of interpersonal behaviour during the course of the interview. Absent $ Definition does not apply $ % & ' *
Minimal uestionable pathologyB may at may the distant! upper e*treme ofinterest normal with resisting involved others $
N&0
POOR RAPPORT 3 8ac2 of interpersonal empathy! openness in conversation and sense closeness!of interest or involvement with the interviewer. his is distancing andinterpersonal reduced verbal and nonverbal communication. evidenced by 1asis 2! !atin, 3+nterpersonal behaviour during the course of the interview. $ % & ' *
N'0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild$ onversation is characterised by a stilted! strained or artificial tone. +t may lac2 emotional depth or tend to remain on an impersonal! intellectual plane. $ Patient typically is aloof! with interpersonal distance 1uite evident. Patient may Mde!ate answer 1uestions mechanically! act bored! or e*press disinterest. $ Disinvolvement is obvious and clearly impedes the productivity of the Mde!ate Se"e!e interview. Patient may tend to avoid eye or face contact. Se"e!e$ Patient is highly indifferent! with mar2ed interpersonal distance. Answers are perfunctory! and there is little nonverbal evidence of involvement. Eye and face contact are fre1uently $avoided. Patient is totally uninvolved with the interviewer. Patient appears to be E#t!eme indifferentcompletely and consistently avoids verbal and nonverbal interactions during the interview.
PASSIVE 6APAT4ETIC SOCIAL 8IT4DRA8AL 3 interest and initiative in Diminished social interactions due to passivity! apathy! anergy or avolition. his interpersonal involvements and neglect of activities of daily living. leads to reduced 1asis 2! !atin, 7 on social behaviour from primary care wor2ers or family. Heports $ % & ' *
N0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits $ Shows occasional interest in social activities but poor initiative.
DIFFICULTY IN A1STRACT T+mpairment 4IN9ING 3 in the use of the abstract$symbolic mode of thin2ing! as evidenced by difficulty in classification! forming generalisations and or egocentric thin2ing in problem$ proceeding beyond concrete solving tas2s. 1asis 2! !atin, 3 Hesponses to 1uestions on similarities and proverb interpretation!
and use of concrete vs. abstract mode during the course of the interview. Absent $ Definition does not apply $ % & ' *
Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits $ ends to give literal or personalis ed interpretations to the more difficult proverbs Mild and may have some problems with concepts that are fairly abstract or remotely related. Mde!ate $formulate >ften a concrete mode. 4as difficulty with most proverbs and some andnot vacuous common do canserve or metaphors loc2ed as autilises basis classifications into or for similes! functional classification. and for aspects! simple onlyhis the salient categories. most rating features simple may Even apply and ofsalient similarities. idiosyncratic to those and functional who hin2ing cannot categories. ends to be distracted aspects and salient features. Mde!ate S either E Se"e!e proverbs is interpretations. attributes even interact $t an $minimally
N0
LAC9 OF SPONTANEITY AND FLO8 OF CONVERSATION Heduction in3 the normal flow of communication associated with apathy! avolition! defensiveness or is manifested by diminished fluidity and productivity of the verbal cognitive deficit. his interactional process. 1asis 2!ognitive$verbal !atin, 3 processes observed during the course of interview. $ % & '
*
N*0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild ? onversation shows little initiative. Patient-s answers tend to be brief and unembellished! re1uiring direct and leading 1uestions by the interviewer. Mde!ate ? onversation lac2s free flow and appears uneven or halting. 8eading 1uestions are fre1uently needed to elicit ade1uate responses and proceed with conversation. $ Patient shows a mar2ed lac2 of spontaneity and openness! replying to Mde!ate Se"e!e the interviewer-s 1uestions with only one or two brief sentences. Se"e!e $ Patient-s responses are limited mainly to a few words or short phrases intended to avoid or curtail communication. /e.g. C+ don-t 2now! C+-m not at liberty to say. onversation is seriously impaired as a result and the interview is highly unproductive. $ erbal output is restricted to! at most! an occasional utterance! ma2ing E#t!eme conversation not possible.
STEREOTYPED Decreased T4IN9ING fluidity! 3 spontaneity and fle*ibility of thin2ing! as evidenced in rigid! repetitious or barren thought content. 1asis 2! !atin, 3 ognitive$verbal processes observed during the interview. $ % & ' *
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ Some rigidity shown in attitude or beliefs. Patient may refuse to consider alternative positions or have difficulty in shifting from one idea to another. Mde!ate$ onversation revolves around a recurrent theme! resulting in difficulty in shifting to a new topic. Mde!ate Se"e!e $ hin2ing is rigid and repetitious to the point that! despite the interviewer-s efforts! conversation is limited to only two or three dominating topics. Se"e!e ?
G ENERAL G$0
PSYC4OPAT4OLOGY
S CALE (G)
SOMATIC Physical CONCERN 3 complaints or beliefs about bodily illness or malfunctions. may rangehis from a vague sense of ill being to clear$cut delusions of catastrophic physical disease. 1asis 2! !atin, 3 hought content e*pressed in the interview. $ % & ' *
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ Distinctly concerned about health or bodily malfunction! but there is no delusional conviction and overconcern can be allayed by reassurance. or organicof delusions malfunction! a catastrophic butnature! affect is which not fully totally immersed dominate in the these patient-s themes!affect and or $ omplains about poor health or bodily malfunction! but there is no delusional Mde!ate Mde!ate Se"e!e E#t!eme Se"e!e be conviction! illness involving thoughts thin2ing. $diverted Patient ? or Numerous can bodily these and by is preoccupied the themes overconcern malfunction! $ interviewer Patient andbut fre1uently e*presses by iscan not or one with else be preoccupied orreported some allayed numerous patient a feweffort. clear$cut by somatic reveals by reassurance. or them. fre1uent one delusions delusions! or complaints twoabout or clear$cut only physical about a delusions fewphysical somatic disease
G%0
AN5IETY 3 Sub,ective e*perience of nervousness! worry! apprehension or ranging fromrestlessness! e*cessive concern about the present or future to feelings panic. 1asis 2!of!atin, 3 report during the course of interview and corresponding erbal
physical manifestations. $ % & '
*
G&0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits $ E*presses some worry! overconcern or sub,ective restlessness! but no somatic and Mild behavioural conse1uences are reported or evidenced. Mde!ate $ Patient reports distinct symptoms of nervousness! which are reflected in mild physical manifestations such as fine hand tremor and e*cessive perspiration. Mde!ate Se"e!e$ Patient reports serious problems of an*iety which have significant physical and behavioural conse1uences! such as mar2ed tension! poor concentration! palpitations or impaired sleep. Se"e!e $ Sub,ective state of almost constant fear associated with phobias! mar2ed restlessness or numerous somatic manifestations. $ Patient-s life is seriously disrupted by an*iety! which is present almost constantly E#t!eme and at times reaches panic proportion or is manifested in actual panic attac2s.
GUILT FSense of remorse $ or self$blame for real or imagined misdeeds in the EELINGS past. 1asis 2! !atin,report 3 erbal of guilt feelings during the course of interview and the
influence on attitudes and thoughts. $ % & '
*
G'0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild ? uestioning elicits a vague sense of guilt or self$blame for a minor incident! but the clearly is not overly concerned. patient $ Patient e*presses distinct concern over his responsibility for a real incident in Mde!ate his life but is not pre$occupied with it and attitude and behaviour are essentially unaffected. Mde!ate Se"e!e $ Patient e*presses a strong sense of guilt associated with self$ deprecation or the belief that he deserves punishment. he guilt feelings may have adelusional basis! may be volunteered spontaneously! may be a source of preoccupation and6or depressed mood! and cannot be allayed readily by the interviewer. Se"e!e $ Strong ideas of guilt ta2e on a delusional 1uality and lead to an attitude of hopelessness or worthlessness. he patient believes he should receive harsh sanctions as such punishment. E#t!eme $ Patient-s life is dominated by unsha2able delusions of guilt! for which he feels deserving of drastic punishment! such as life imprisonment! torture! or death. here may be suicidal thoughts or attribution of others- problems to one-s own past associated misdeeds.
TENSION>vert 3 physical manifestations of fear! an*iety! and agitation! such as tremor! profuse sweating and restlessness. stiffness! 1asis 2! !atin, 3 erbal report attesting to an*iety and thereupon the severity o physical manifestations of tension observed during the interview. $ % & ' *
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Posture and movements indicate slight apprehensiveness! such as minor Mild fidgety sha2ing! for such $$e*ample! Pronounced as behaviour! rapid profuse may restless tension sweating be obvious constantly pacing toand the hand and restlessness! point fidgeting! tremor! inability that e*cessive interpersonal to unable but remain can toperspiration! conduct sit seated interactions still for for in longer the long! or interview nervous are or than disrup show a isrigidity! ted. nothe occasional restlessness! shifting of position! or fine rapid hand tremor. Mde!ate Se"e!e E#t!eme M patient d$ Pronounced te:ar2ed mannerisms. significantly hyperventilation. minute! ma2es sustained $which ASclearly affected. conversation tension tension nervous isisappearance manifested evidenced not possible. by emerges signs numerous of from panic manifestations! various or gross manifestations! motor such acceleration! as nervous such as
G0
7 movements or posture as characterised be a aw2ward! stilted! disorganised! or biGarre appearance. 1asis 2! !atin, >bservation 3 of physical manifestations during the course o interview as well as reports from primary care wor2ers or family. $ % & ' *
G0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ Slight aw2wardness in movements or minor rigidity of posture ? :ovements are notably aw2ward or dis,ointed! or an unnatural posture is Mde!ate maintained for brief periods. Mde!ate Se"e!e$ >ccasional biGarre rituals or contorted posture are observed! or an abnormal position is sustained for e*tended periods. Se"e!e $ Fre1uent repetition of biGarre rituals! mannerisms or stereotyped movements! or a contorted posture is sustained for e*tended periods. $ Functioning is seriously impaired by virtually constant involvement in ritualistic! E#t!eme or manneristic! stereotyped movements or by an unnatural fi*ed posture which is sustained most of the time.
Feelings $ DEPRESSION
of sadness! discouragement! helplessness and pessimism.
1asis 2!erbal !atin,report 3 of depressed mood during the course of interview and its observed influence on attitude and behaviour. $ % & '
*
G*0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild$ E*presses some sadness of discouragement only on 1uestioning! but there is no evidence of depression in general attitude or demeanor. Mde!ate$ Distinct feelings of sadness or hopelessness! which may be spontaneously divulged! but depressed mood has no ma,or impact on behaviour or social functioning and can be cheered up. the patient usually Mde!ate Se"e!e $ Distinctly depressed mood is associated with obvious sadness! pessimism! loss of social interest! psychomotor retardation and some interference in appetite and sleep. he patient cannot be easily cheered up. Se"e!e $ :ar2edly depressed mood is associated with sustained feelings of misery! occasional and worthlessness. +n addition! there is ma,or interference in crying! hopelessness appetite andwell as in normal motor and social functions! with possible signs of self$ or sleep as neglect. E#t!eme $ Depressive feelings seriously interfere in mos t ma,or functions. he manifestations include fre1uent crying! pronounced somatic symptoms! impaired concentration! psychomotor retardation! social disinterest! self neglect! possible depressive or nihilistic delusions and6or possible suicidal thoughts or action.
MOTOR RETARDATION Heduction in7 motor activity as reflected in slowing or lessening or movements and speech! diminished responsiveness of stimuli! and reduced tone. 1asis 2!body !atin, 3 :anifestations during the course of interview as well as reports by
primary care wor2ers as well as family. $ % & ' *
Absent $ Definition does not apply $ uestionable pathologyB may be atand the occupational upper e*treme of normal limits Minimal unproductive $ Patient orisdelimits almost functioning completely immobile in social and virtually unresponsive situations. to Patient e*ternal Mild noticeable diminution inin rate of movements andbespeech. may be Mde!ate E#t!eme M$ Slight S d tebut S productivity somewhat usually Essentially $$:ovements Patient stimuli. be found underproductive the including is ? day clearly A sitting are mar2ed is e*tremely spent lon slow or lying reduction sitting in inconversation movements! slow! down. nse idly laten resulting ormotor lying and e*tended activity down. in gestures. speech a minimum renders pauses may of communication or characterised activity slowPatient and by speech. highly poor
G:0
UNCOOPERATIVENESS 3 Active refusal to comply with the will of significant others! including the interviewer! hospital staff or family! which may be defensiveness! negativism! re,ection of authority! associated withstubbornness! distrust! hostility or!atin, belligerence. 1asis 2!+nterpersonal 3 behaviour observed during the course of the interview
as well as reports by primary care wor2ers or family. $ % & '
*
G;0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ omplies with an attitude of resentment! impatience! or sarcasm. :ay ob,ectinoffensively to sensitive probing during the interview. $ >ccasional outright refusal to comply with normal social demands! such as Mde!ate ma2ing own bed! attending scheduled programmes! etc. he patient may pro,ect a hostile! defensive or negative attitude but usuallyiscan be wor2ed with. $ Patient fre1uently incompliant with the demands of his milieu and may be Mde!ate Se"e!e characterised by other as an Coutcast or having Ca serious attitude problem.
UNUSUAL T4OUG4T CONTENT hin2ing characterised $ by strange! fantastic or biGarre ideas! ranging from those which are remote or atypical to those which are distorted! and patently absurd. 1asis 2! illogical !atin, 3 hought content e*pressed during the course of interview. $ % & '
*
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ hought content is somewhat peculiar! or idiosyncratic! or familiar ideas are framed$ +deas in an odd conte*t. distorted and occasionally seem 1uite biGarre. are fre1uently Mde!ate $ Patient e*presses many strange and fantastic thoughts! /e.g. 7eing the Mde!ate Se"e!e adopted son of a 2ing! being an escapee from death row! or some which are patently absurd /e.g. 4aving hundreds of children! receiving radio messages from outer space from a tooth filling.e*presses many illogical or absurd ideas or some which have a distinctly $ Patient Se"e!e biGarre 1uality /e.g. having three heads! being a visitor from another planet. E#t!eme $ hin2ing is replete with absurd! biGarre and grotes1ue ideas.
G$<0 DISORIENTATION 8ac2 of$ awareness of one-s relationship to the milieu! including persons! place and time! which may be due to confusion or withdrawal. 1asis 2! !atin, 3 Hesponses to interview 1uestions on orientation. $ % &
' *
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild$ 5eneral orientation is ade1uate but there is some difficulty with specifics. For e*ample! patient 2nows his location but not the street address! 2nows hospital staff names but not theirmonth functions! 2nows the day of the wee2 with an ad,acent day! or errs in the date the but confuses by more thanmay twobe narrowing of interest evidenced by familiarity with the days. here immediate e*tended milieu! suchbut as not ability to identify staff but not the mayor! governor! or president. $ >nly partial success inor recognising persons! places and time. For e*ample! patient Mde!ate primary hospital vague the whereabouts! here $year :ar2ed is notion but therapist correctly gross not of failure confuses confusion its where but or name! nearly in not he the recognising many 2nows is date but total andnot other by seems the ignorance more 2now persons! name direct unfamiliar than the of about care place current the one wor2ers! city one-s year! with and month! but time. can most location! not 2nows name day For the people borough e*ample! of the the only wee2 in current year one hisor or or milieu. patient oreven year season two has 2nows he is in a Mde!ate Se"e!e E#t!eme Se"e!e but district! 4e individuals and the no may most season. $not even Patient $ 2nowledge onsiderable sure 2nows identify familiar inof appears his thepeople! current of month. name failure his completely of life. such his in recognising asdisorientated parents! spouse! persons! withfriends regard place and to persons! time. primary Patient place therapist. has andonly time.a
G$$0
POOR ATTENTION Failure$ in focused alertness manifested by poor concentration! distractibility from internal and e*ternal stimuli! and difficulty in harnessing! sustaining or shifting focus to new during stimuli.the course of interview. 1asis 2! !atin, 7 :anifestations $ % & ' *
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild$ 8imited concentration evidenced by occasional vulnerability to distraction and faltering attention toward the end of the interview. $ onversation is affected by the tendency to be easily distracted! difficulty in long Mde!ate sustaining concentration on a given topic! or problems in shifting attention to new topics. Mde!ate Se"e!e $ onversation is seriously hampered by poor concentration! distractibility! and difficulty in shifting focus appropriately.. $ Patient-s attention can be harnessed for only brief moments or with great effort! Se"e!e due to mar2ed distraction by internal or e*ternal stimuli. E#t!eme $ Attention is so disrupted that even brief conversation is not possible.
G$%0 LAC9 OF =UDGEMENT AND INSIG4T +mpaired awareness $ or understanding of one-s own psychiatric condition and life situation. his is evidenced by failure psychiatric symptoms! denial of need for psychiatric to recogniseillness past ororpresent hospitalisation treatment! decisions characterised byorpoor anticipation or conse1uences! and unrealistic short$term and long$range planning. 1asis 2! !atin, 7 hought content e*pressed during the interview. $ % & '
*
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ Hecognises having a psychiatric disorder but clearly underestimates its seriousness! the implications for measures to avoid relapse. Future planning treatment! or the importance of ta2ing may be poorly conceived. Mde!ate $ Patient shows only a vague or shallow recognition of illness. here may be fluctuations ac2nowledgement of in being ill or little awareness of ma,or symptoms which are present! such as delusions! disorganised thin2ing! suspiciousness and social withdrawal. he patient may rationalise thein terms of its relieving lesser symptoms! such as an*iety! need for treatment tension andSe"e!e sleep difficulty. Mde!ate $ Ac2nowledges past but not present psychiatric disorder. +f challenged! the patient may concede the presence of some unrelated or insignificant symptoms! which tend to be e*plained away byor delusional thin2ing. he need for psychiatric treatment gross misinterpretation similarly goesdenies unrecognised. $ Patient ever having had a psychiatric disorder. 4e disavows the presence Se"e!e of any psychiatric symptoms in the past or present and! though compliant! denies the need for treatment and hospitalisation. E#t!eme $ Emphatic denial of past and present psychiatric illness. urren t hospitalisation and treatment are given a delusional interpretation /e.g. as punishment fro misdeeds! as persecution by thus tormentors! etc! and the patient refuse to cooperate with therapists! medication or other aspects of treatment.
G$&0 DISTUR1ANCE OF VOLITION Disturbance ? in the wilful initiation! sustenance and control of one-s thoughts! behaviour! movements and speech. 1asis 2! !atin,content 3 hought and behaviour manifested in the course of interview. $ % & ' *
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ here is evidence of some indecisiveness in conversation and thin2ing! which may impede verbal and cognitive processes to a minor e*tent. onversation Patient shows ? Almost may pronounced becomplete marred indecision by failure alteration of that volition impedes in thin2ing! is manifested the initiation and in conse1uence! byand gross continuation inhibition verbalof $ Patient is often ambivalent and shows clear difficulty in reaching decisions. Mde!ate M social S E tdspeech tefunctioning Sresulting cognitive of functions! and motor $ Disturbance movement such activities! as$ dressing Disturbance of in and are immobility volition which clearly or grooming! of interferes also impaired. volition and6or mayand be in mutism. interferes the evidence mar2edly e*ecution ininthin2ing affects halting of simple speech. as speech. well automatic as behaviour. motor
G$'0 POOR I$MPULSE CONTROL Disordered regulation and control of action on inner urges! resulting in sudden! unmodulated! arbitrary or misdirected discharge of tension and emotions about conse1uences. 1asis 2! without !atin, 7 concern 7ehaviour during the course of interview and reported by primary
care wor2ers or family. $ % & '
*
G$0
Absorption3 PREOCCUPATION
with internally generated thoughts and feelings and with autistic e*periences to the detriment of reality orientation and ad aptive behaviour. 1asis 2! !atin, +nterpersonal $ behaviour observed during the course of interview. $ % & '
*
G$0
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ Patient tends to be easily angered and frustrated when facing stress or denied gratification but rarely acts on impulse. Mde!ate $ Patient gets angered and verbally abusive with minimal provocation. :ay be occasionally threatening! destructive! or have one or two episodes involving physical confrontation or$ aPatient minore*hibits brawl. repeated impulsive episodes involving verbal abuse! Mde!ate Se"e!e destruction of property! or physical threats. here may be one or two episodes involving serious assault! for which the patient re1uires isolation! physical restraint! or p.r.n. sedation. Se"e!e $ Patient fre1uently is impulsive aggressive! threatening! demanding! and without destructive! any apparent consideration of conse1uences. Shows assualtive behaviour and may also be se*ually offensive and possibly respond behaviourally to hallucinatory commands. E#t!eme $ Patient e*hibits homicidal! se*ual assaults! repeated brutality! or self$destructive behaviour. constant directHe1uires supervision or e*ternal constraints because of inability to control dangerous impulses.
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild $ E*cessive involvement with personal needs or problems! such that conversation veers bac2 to egocentric themes and there is diminished concerned e*hibited toward others.occasionally appears self$absorbed! as if daydreaming or involved with $ Patient Mde!ate internal e*periences! which interferes with communication to a minor e*tent. $ Patient Mde!ate Se"e!eoften appears to be engaged in autistic e*periences! as evidenced by behaviours that significantly intrude on social and communicational functions! such as athe presence of vacant stare! muttering or tal2ing to oneself! or involvement with stereotyped motor patterns. $ :ar2ed preoccupation with autistic e*periences! which seriously delimits Se"e!e concentration! ability to converse! and orientation to the milieu. he patient fre1uently may be observed smiling! laughing! muttering! tal2ing! or shouting to himself. E#t!eme $ 5ross absorption with autistic e*periences! which profoundly affects all ma,or realms of behaviour. he patient constantly may be responding verbally or behaviourally hallucinations to and show little awareness of other people or the e*ternal milieu.
Diminished $ social involvement associated with unwarranted fear! hostility! or distrust.
ACTIVE SOCIAL AVOIDANCE
1asis 2! !atin, 3 Heports of social functioning primary care wor2ers or family. $ % & ' *
Absent $ Definition does not apply Minimal $ uestionable pathologyB may be at the upper e*treme of normal limits Mild$ Patient seems ill at ease in the presence of others of others and prefers to spend persuaded patient persecutory shows $ $Patient Patient ordelusions. may a strong participates cannot terminate tendency obe theengaged prematurely ine*tent very to brea2 few possible! in social social off on account interactions! he activities activities avoids of an*iety! because all because and interactions generally suspiciousness! of ofpronounced fear!and he hostility! tends remains fear s! or toor time alone! although he participates in social functions when re1uired. Mde!ate E#t!eme S Se"e!e hostility. despite isolate isolated $himself othersdistrust. from Patient hostility! others. $efforts from Patient begrudgingly Jhen or others. to approached! fearfully engage attends him. or angrily the ends all or 2eeps most to spend social away unstructured from activities many but time social may alone. interactions needs to be
