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18 Psychiatry

18.01 Psychological General Well-Being Schedule


18.02 The SCL-90 (Symptom Check List) Outpatient Psychiatric Rating Scale
18.03 Mental Status Examination
18.03.01 Mini-Mental State Examination
18.03.02 Abbreviated Mental Test
18.03.03 Confusion Rating
18.03.04 The Set Test of Isaacs and Akhtar
18.04 Evaluation of Depression
18.04.01 Geriatric Depression Scale
18.04.02 CES-D Self-Report Depression Scale
18.04.03 The Zung Self-Rating Depression Scale
18.04.04 Beck Inventory for Measuring Depression
18.04.05 The Brief Depression Scale of Koenig et al
18.04.06 The Edinburgh Postnatal Depression Scale
18.04.07 The Harvard Department of Psychiatry and National Depression Screening Day
Scale (HANDS)
18.04.08 The Hopelessness Scale of Beck et al
18.04.09 Indications to Screen a Patient for Depression
18.04.10 The Montgomery-Asberg Depression Rating Scale (MADRS)
18.05 Evaluation of the Obsessive-Compulsive Personality
18.05.01 Maudsley Obsessional-Compulsive Inventory
18.05.02 Lynfield Obsessional-Complusive Questionnaires
18.06 Anxiety Disorders
18.06.01 Habits of Nervous Tension
18.06.02 The Anxiety Status Inventory (ASI) of Zung
18.06.03 The Self-rating Anxiety Scale (SAS) of Zung
18.06.04 The Hospital Anxiety and Depression Scale (HAD Scale)
18.07 Psychological Response to Traumatic Events
18.07.01 The Revised Impact of Event Scale
18.07.02 Acute Stress Disorder
18.08 Schizophrenia
18.08.01 The Chestnut Lodge Prognostic Scale for Patients with Chronic Schizophrenia
18.09 Tardive Dyskinesia
18.09.01 Dyskinesia Identification System: Condensed User Scale (DISCUS)
18.09.02 Abnormal Involuntary Movement Scale (AIMS)

18.10 Neuroleptic Malignant Syndrome


18.10.01 Diagnostic Criteria of Caroff et al for the Neuroleptic Malignant Syndrome
18.11 The Serotonin Syndrome
18.11.01 Criteria for the Diagnosis of the Serotonin Syndrome
18.11.02 The Serotonin Syndrome Scale
18.12 Attention Deficit Hyperactivity Disorder (ADHD)
18.12.01 Parents' Rating Scale for the Attention Deficit Hyperactivity Disorder
18.12.02 Wender Utah Rating Scale for the Attention Deficit Hyperactivity Disorder
18.12.03 Attention Deficit Hyperactivity Disorder ADD/H Adolescent Self-Report Scale
Short Form
18.13 Screening Children for Psychosocial Dysfunction
18.13.01 Pediatric Symptom Checklist for Screening School-Age Children for
Psychosocial Dysfunction
18.14 Shared Delusional States
18.14.01 Mass Psychogenic Illness (Environmental Somatization Syndrome)
18.14.02 Delusions Shared By Two or More People (Folie a Deux, etc.)
18.15 Eating Disorders
18.15.01 Criteria for Bulimia Nervosa
18.15.02 Criteria for Anorexia Nervosa
18.15.03 Criteria for Eating Disorder Not Otherwise Specified
18.15.04 The SCOFF Questionnaire Screening Insturment for Eating Disorders
18.15.05 The Eating Attitudes Test for Symptoms of Anorexia Nervosa
18.16 Psychological Measures of Alcohol Abuse
18.16.01 The Obsessive Compulsive Drinking Scale
18.16.02 The Brief Michigan Alcoholism Test
18.16.03 The TWEAK Screening Test
18.16.04 The Alcohol Use Disorders Identification Test (AUDIT) Core Questionnaire
18.16.05 The Canterbury Alcoholism Screening Test (CAST)
18.17 Evaluation of Substance Abuse
18.17.01 Criteria for Substance Dependence
18.17.02 Evaluating Adolescent Substance Abuse
18.17.03 Screening for Adolescent Substance Abuse Using the CRAFFT Questionnaire
18.17.04 Fagerstrom Test for Nicotine Dependence
18.17.05 Problem Severity Index (PSI) for Patients with Drug Dependence
18.18 Evaluation of Abusive Behavior
18.18.01 Types of Abusive Behavior
18.19 Evaluation of Manic States

18.19.01 Manic Rating Scale


18.19.02 Manic State Rating Scale
18.19.03 Longitudinal Rating Scale of Petterson et al for the Manic State
18.19.04 Manic State Checklist for Nurses
18.20 Suicide and Self-Harm
18.20.01 Scale for Suicide Ideation of Beck et al.
18.20.02 Risk Factors for Suicide in Adults
18.21 Seasonal Affective Disorder (SAD)
18.21.01 Diagnostic Criteria for Seasonal Affective Disorder
18.22 Violent and Aggressive Behaviors
18.22.01 Rating Scale of Delgado-Escueta et al for Aggressive Behavior
18.23 Dementia and Behavioral Problems in the Elderly and Institutionalized Persons
18.23.01 The Nursing Home Behavior Problem Scale
18.23.02 Functional Dementia Scale (FDS)
18.23.03 Agitated Behavior Scale (ABS)
18.24 Electroconvulsive Therapy (ECT)
18.24.01 Conditions Associated with Adverse Events Following Electroconvulsive
Therapy
18.24.02 Indications for Use of Electroconvulsive Therapy
18.25 Screening for Mental Disorders in Primary Care
18.25.01 The Patient Questionnaire Format for PRIME-MD
18.25.02 Screening for Mental Disorders in Medical Outpatients Using the Predictors of
Jackson et al
18.26 Tic Disorders
18.26.01 Clinical Features of Tourette Syndrome
18.27 Activity-Related Addictive Behaviors
18.27.01 DSM-IV Criteria for Pathological Gambling
18.27.02 Screening Population Groups at Increased Risk for Pathologic Gambling
18.01 Psychological General Well-Being Schedule
Overview:
The Psychological General Well-Being Schedule is an index to measure a person's
subjective well-being. The person self-reports on 22 items which are indicators of 6
affective states.
Affective states assessed:
anxiety

depressed mood
sense of positive well-being
self-control
general health
vitality
Questions
Instructions: This section of the examination contains questions about how you feel and
how things have been going with you. For each question check the answer which best
applies to you.
(1) How have you been feeling in general during the past month?
in excellent spirits [5]
in very good spirits [4]
in good spirits mostly [3]
I have been up and down in spirits a lot [2]
in low spirits mostly [1]
in very low spirits [0]
(2) How often were you bothered by any illness, bodily disorder, aches or pains during
the past month?
every day [0]
almost every day [1]
about half of the time [2]
now and then, but less than half the time [3]
rarely [4]
none of the time [5]
(3) Did you feel depressed during the past month?
Yes - to the point that I felt like taking my life [0]
Yes - to the point that I didn't care about anything [1]
Yes - very depressed almost every day [2]
Yes - quite depressed several times [3]
Yes - a little depressed now and then [4]
No - never felt depressed at all [5]
(4) Have you been in firm control of your behavior, thoughts, emotions or feelings during
the past month?
Yes, definitely so [5]
Yes, for the most part [4]
generally so [3]
not too well [2]
No, and I am somewhat disturbed [1]
No, and I am very disturbed [0]

(5) Have you been bothered by nervousness during the past month?
extremely so - to the point where I could not work or take care of things [0]
very much so [1]
quite a bit [2]
some - enough to bother me[3]
a little [4]
not at all [5]
(6) How much energy, pep, or vitality did you have during the past month?
very full of energy - lots of pep[5]
fairly energetic most of the time [4]
my energy energy varied quite a bit [3]
generally low energy or pep [2]
very low in energy or pep most of the time [1]
no energy or pep at all - I felt drained, sapped [0]
(7) I felt downhearted and blue during the past month:
none of the time [5]
a little of the time [4]
some of the time [3]
a good bit of the time [2]
most of the time [1]
all of the time [0]
(8) Were you generally tense or did you feel any tension during the past month?
Yes - extremely tense, most or all of the time [0]
Yes - very tense most of the time [1]
Not generally tense, but did feel fairly tense several times [2]
I felt a little tense a few times [3]
My general tension level was quite low [4]
I never felt tense or any tension at all [5]
(9) How happy, satisfied, or pleased have you been with your personal life during the
past month?
extremely happy - could not have been more satisfied or pleased [5]
very happy most of the time [4]
generally satisfied - pleased [3]
sometimes fairly happy [2]
generally dissatisfied, unhappy [1]
very dissatisfied or unhappy most or all of the time [0]
(10) Did you feel healthy enough to carry out the things you like to do or had to do
during the past month?
Yes - definitely so [5]
for the most part [4]
health problems limited me in some important ways[3]

I was only health enough to take care of myself [2]


I needed some help in taking care of myself [1]
I needed someone to help me with most or all of the things I had to do [0]
(11) Have you felt so sad, discouraged, or hopeless or had so many problems that you
wondered if anything was worthwhile during the past month?
extremely so - to the point that I have just about given up [0]
very much so [1]
quite a bit [2]
some - enough to bother me [3]
a little bit [4]
not at all [5]
(12) I woke up feeling fresh and rested during the past month:
none of the time [0]
a little of the time [1]
some of the time [2]
a good bit of the time [3]
most of the time [4]
all of the time [5]
(13) Have you been concerned, worried or had any fears about your health during the past
month?
extremely so [0]
very much so [1]
quite a bit [2]
some but not a lot [3]
practically never [4]
not at all [5]
(14) Have you had any reason to wonder if you were losing your mind, or losing control
over the way you act, talk, think, feel or of your memory during the past month?
not at all [5]
only a little [4]
some but not enough to be concerned or worried about [3]
some, and I'm a little concerned [2]
some and I'm quite concerned [1]
very much so and I am very concerned [0]
(15) My daily life was full of things that were interesting to me during the past month.
none of the time [0]
a little of the time [1]
some of the time [2]
a good bit of the time [3]
most of the time [4]
all of the time [5]

(16) Did you feel active, vigorous, or dull sluggish during the past month?
very active, vigorous every day [5]
mostly active, vigorous - never really dull, sluggish [4]
fairly active, vigorous - seldom dull, sluggish [3]
fairly dull, sluggish - seldom active, vigorous [2]
mostly dull, sluggish - never really active, vigorous
very dull, sluggish every day [0]
(17) Have you been anxious, worried, or upset during the past month?
extremely so - to the point of being sick or almost sick [0]
very much so [1]
quite a bit [2]
some - enough to bother me [3]
a little bit [4]
not at all [5]
(18) I was emotionally stable and sure of myself during the past month:
none of the time [0]
a little of the time [1]
some of the time [2]
a good bit of the time [3]
most of the time [4]
all of the time [5]
(19) Did you feel relaxed, at ease or high strung, tight or keyed up during the past month?
relaxed and at ease all month [5]
relaxed and at ease most of the time [4]
generally felt relaxed but at times felt fairly high strung [3]
generally felt high strung but at times felt fairly relaxed [2]
high strung, tight or keyed-up most of the time [1]
felt high strung, tight or keyed-up the whole month [0]
(20) I felt cheerful, lighthearted during the past month:
none of the time [0]
a little of the time [1]
some of the time [2]
a good bit of the time [3]
most of the time [4]
all of the time [5]
(21) I felt tired, worn out, used up or exhausted during the past month:
none of the time [5]
a little of the time [4]
some of the time [3]
a good bit of the time [2]

most of the time [1]


all of the time [0]
(22) Have you been under or felt you were under any strain, stress or pressure during the
past month?
Yes - almost more than I could bear or stand [0]
Yes - quite a bit of pressure [1]
Yes, some - more than usual [2]
Yes, some - but about usual [3]
Yes - a little [4]
not at all [5]
Interpretation
score for each affective group =
= SUM(points assigned for each question in group)
where:
the number in square brackets represents the points assigned for a selected answer
Affective Group
anxiety
depressed mood
positive well-being
self-control
general health
vitality

Group
anxiety

Questions
5, 8, 17, 19, 22
3, 7, 11
1, 9, 15, 20
4, 14, 18
2, 10, 13
6, 12, 16, 21

Low Score
extremely bothered by
nervousness, very tense, anxious,
worried, upset; felt under heavy
pressure
depressed mood intensely or often felt depressed;
downhearted and blue; hopeless
positive wellbeing
self-control

Range of Scores
0 - 25
0 - 14
0 - 20
0 - 15
0 - 15
0 - 20

High Score
not bothered by nerves; low
tension; not anxious; relaxed; little
or no stress or strain

never or rarely felt depressed;


downhearted and blue; or
hopeless
low spirits; unhaooy; never or
in excellent spirits; happy with
seldom felt life interesting or
life; daily life interesting; felt
cheerful
cheerful
very concerned or disturbed about in definite control of behavior,
losing self-control; seldom felt
thoughts, emotions and feelings;
emotionally stable
emotionally stable

general health

vitality

often bothered by illness, bodily


disorders; needed help in caring
for self; worried or fearful about
health
low in energy; seldom waking
fresh; rested; dull, sluggish; tired,
worn-out

rarely if ever bothered by illness;


healthy enough to do things; not
fearful or worried about health
full of energy, pep; waking fresh,
rested; felt active, vigorous; never
felt tired or worn-out

References:
Dupuy HJ. Chapter 9: The Psychological General Well-Being (PGWB) Index. pages 170183; Appendix I: Selected test instruments. pages 353-356. IN: Wenger NK, Mattson
ME, et al. Assessment of Quality of Life in Clinical Trials of Cardiovascular
Therapies. Le Jacq Publishing Inc. 1984.
McDowel I, Newell C. Measuring Health - A Guide to Rating Scales and Questionnaires,
Second Edition. Oxford University Press. 1996. pages 206-213
18.02 The SCL-90 (Symptom Check List) Outpatient Psychiatric Rating Scale
Overview:
The SCL-90 is a self-reporting, clinical symptom rating scale consisting of 90 questions.
It is designed for use with psychiatric outpatients. Responses indicate symptoms
associated with 9 psychiatric constructs.
Constructs represented
somatization (perceptions of bodily dysfunction)
obsessive-compulsive
interpersonal sensitivity (feelings of personal inadequacy or inferiority)
depression
anxiety
hostility
phobic anxiety
paranoid ideation
psychoticism
Instructions
Below is a list of problems and complaints that people sometimes have. Please read each
one carefully. After you hvae done so, please fill in one of the numbered spaces to the
right that best describes HOW MUCH THAT PROBLEM HAS BOTHERED OR
DISTRESSED YOU DURING THE PAST, INCLUDING TODAY. Mark only one
numbered space for each problem and do not skip any items. Mark your marks carefully
using a No 2 pencil. DO NOT USE A BALLPOINT PEN. If you change your mind,
erase your first answer completely. Please do not make any extra marks on the shet.
Please read the example below before beginning.
Responses

Points

not at all
a little bit
moderately
quite a bit
extremely
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

0
1
2
3
4

Symptom
headaches
nervousness or shakiness inside
unwanted thoughts, words, or ideas that won't leave your
mind
faintness or dizziness
loss of sexual interest or pleasure
feeling critical of others
the idea that someone else can control your thoughts
feeling others are to blame for most of your troubles
trouble remembering things
worried about sloppiness or carelessness
feeling easily annoyed or irritated
pains in heart or chest
feeling afraid in open spaces or on the streets
feeling low in energy or slowed down
thoughts of ending your life
hearing voices that other people do not hear
trembling
feeling that most people cannot be trusted
poor appetite
crying easily
feeling shy or uneasy with the opposite sex
feeling of being trapped or caught
suddently scared for no reason
temper outbursts that you could not control
feeling afraid to go out of your house alone
blaming yourself for things
pains in lower back
feeling blocked in getting things done
feeling lonely
feeling blue
worrying too much about things
feeling no interest in things
feeling fearful
your feelings being easily hurt
other people being aware of your private thoughts

36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74

feeling others do not understand you or are


unsympathetic
feeling that people are unfriendly or dislike you
having to do things very slowly to insure correctness
heart pounding or racing
nausea or upset stomach
feeling inferior to others
soreness of your muscles
feeling that you are watched or talked about by others
trouble falling asleep
having to check and double-check what you do
difficulty making decisions
feeling afraid to travel on buses, subways or trains
trouble getting your breath
hot or cold spells
having to avoid certain things, places or activities because
they frighten you
you mind going blank
numbness or tingling in parts of your body
a lump in your throat
feeling hopeless about the future
trouble concentrating
feeling weak in parts of your body
feeling tense or keyed up
heavy feelings in your arms or legs
thoughts of death or dying
overeating
feeling uneasy when people are watching or talking about
you
having thoughts that are not your own
having urges to beat, injure or harm someone
awakening in the early morning
having to repeat the same actions such as touching,
counting or washing
sleep that is restless or disturbed
having urges to break or smash things
having ideas or beliefs that others do not share
feeling very self-conscious with others
feeling uneasy in crowds, such as shopping or at a movie
feeling everything is an effort
spells of terror or panic
feeling uncomfortable about eating or drinking in public
getting into frequent arguments

75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90

feeling nervous when you are left alone


others not giving your proper credit for your
achievements
feeling lonely even when you are with people
feeling so restless you couldn't sit still
feelings of worthlessness
feeling that familiar things are strange or unreal
shouting or throwing things
feeling afraid you will faint in public
feeling that people will take advantage of you if you let
them
having thoughts about sex that bother you a lot
the idea that you should be punished for your sins
feeling pushed to get things done
the idea that something serious is wrong with your body
never feeling close to another person
feelings of guilt
the idea that something is wrong with your mind

Construct
somatization

Number
12

obsessive-compulsive
interpersonal sensitivity
depression

10
9
13

anxiety
anger-hostility
phobic anxiety
paranoid ideation
psychotism
additional scales

10
6
7
6
10
7

Symptoms
1, 4, 12, 27, 40, 42, 48, 49, 52, 53, 56,
58
3, 9, 10, 28, 38, 45, 46, 51, 55, 65
6, 21, 34, 36, 37, 41, 61, 69, 73
5, 14, 15, 20, 22, 26, 29, 30, 31, 32, 54,
71, 79
2, 17, 23, 33, 39, 57, 72, 78, 80, 86
11, 24, 63, 67, 74, 81
13, 25, 47, 50, 70, 75, 82
8, 18, 43, 68, 76, 83
7, 16, 35, 62, 77, 84, 85, 87, 88, 90
19, 44, 59, 60, 64, 66, 89

score for each construct =


= SUM (points for response to each component symptom)
References:
Derogatis LR, Lipman RS, Covi L. SCL-90: An outpatient psychiatric rating scale Preliminary report. Psychopharm Bulletin. 1973; 9: 13-28.
18.03 Mental Status Examination
18.03.01 Mini-Mental State Examination

Overview:
The Mini-Mental examination can be used to assess a person's mental state. It is intended
to be given quickly (usually less than 10 minutes) and easily, which is useful in patients
with only limited spans of attention or cooperation. It can be used over time to assess
changes in status with recovery, further deterioration, or treatment interventions.
Limitations (whence termed "mini")
The test only concentrates on cognitive aspects of mental functions.
The test does not concern mood, abnormal mental experiences or the form of thinking.
Instructions
Take as much time as needed.
Patients with impaired vision or disabilities may require allowances for physical
debilities.
Parameter
Orientation

Registration

Attention and
Calculation
Recall
Language

Item
What is the year?
What is the season?
What is the date?
What is the day (of the week)?
What is the month?
What state are we in?
What county are we in?
What town or city are we in?
What building are we in?
Which street or floor are we on?
Name 3 objects slowly and carefully, then ask the
patient for all 3 items, giving 1 point for each
correct item named. Then repeat the items until the
patient knows all 3.
Serial 7's, from 7 to 35, giving 1 point for each
correct. (Alternative: spell "world" backwards, with
1 point for each correct letter.)
Ask for names of the 3 objects repeated above,
giving 1 point for each correct.
Ask the patient to identify a pencil.
Ask the patient to identify a watch.
Ask the patient to repeat the phrase "No ifs, ands
or buts."
Ask the patient to follow the 3-stage command:
"Take a paper in your right hand, fold it in half, and
put it on the floor."
Read and obey:"Close your eyes."

Points
1
1
1
1
1
1
1
1
1
1
3

3
1
1
1
3

Read and obey: "Write a sentence."


Read and obey: "Copy this simple design." (of two
overlapping pentagons). To score the point, all 10
angles must be present and the two items must
partially overlap.

1
1

mini-mental score =
= (orientation points) + (registration points) + (attention and calculation points) + (recall
points) + (language points)
Interpretation
minimum score: 0
maximum score: 30
mean score for normal individuals: 27.6
mean score in dementia: 9.7
further evaluation is warranted in the elderly if score is < 24.
References:
Folstein MF, Folstein SE, McHugh PR. "Mini-mental State": A practical method for
grading the cognitive state of patients for the clinician. J Psychiat Res. 1975; 12: 189198.
Lachs MS, Feinstein AR, et al. A simple procedure for general screening of functional
disability in elderly patients. Ann Intern Med. 1990; 112: 699-706.
McDowel I, Newell C. Measuring Health - A Guide to Rating Scales and Questionnaires,
Second Edition. Oxford University Press. 1996. pages 314-323
18.03.02 Abbreviated Mental Test
Overview:
The Abbreviated Mental Test can be used to quickly test the cognitive function in elderly
patients. This is also referred to as the Hodkinson's Mental Test Score.
Item
age
time to the nearest hour
year
name of place
recognition of 2 persons
birthday (date and month)
date of World War I
name of your country's Ruler, President or
Prime Minister
able to count from 20 to 1 backwards
address - 42 West Street

Score
1
1
1
1
1
1
1
1
1
1

Interpretation
minimum score: 0
maximum score: 10
a higher score indicates greater cognitive function
a score of 6 is used as the cutoff to separate normal elderly persons from those who are
confused or demented with a correct assignment of 81.5%
References:
Jitapunkul S, Pillay I, Ebrahim S. The Abbreviated Mental Test: Its use and validity. Age
Aging. 1991; 20: 332-336.
Kalra L, Crome P. The role of prognostic scores in targeting stroke rehabilitation in
elderly patients. J Am Geriatr Soc. 1993; 41: 396-400.
Qureshi KN, Hodkinson HM. Evaluation of a ten-question mental test in the
institutionalised elderly. Age Ageing. 1974; 3: 152-157.
Vardon VM, Blessed G. Confusion ratings and abbreviated mental test performance: A
comparison. Age Ageing. 1986; 15: 139-144.
18.03.03 Confusion Rating
Overview:
The Confusion Rating can be used to quickly and simply assess patients for cognitive
impairment. Trends over time may indicate improvement, stability or deterioration in
response to changes in clinical status or to therapeutic interventions.
Parameter
memory

orientation

communication

Finding
complete
occasionally forgetful
short-term loss
short and long term loss
complete
oriented in ward, identifies people correctly
misidentifies but can find way about
cannot find way to bed or toilet without
assistance
completely loss
always clear, retains information
can indicate needs, understands simple verbal
directions, can deal with simple information
cannot understand simple verbal information,
OR cannot indicate needs
cannot understand verbal information, AND
cannot indicate needs; retains some expressive
ability
no effective contact

Points
0
1
2
3
0
1
2
3
4
0
1
2
3

Interpretation:
minimum score 0
maximum score 11
higher scores indicate greater confusion
demented patients had higher scores than other patients (typically 6 or greater); a score
>= 4 correctly classified 91% of demented patients
normal elderly and elderly with psychiatric illnesses such as depression or
schizophrenia had similar scores; a score <= 3 correctly classified nondemented
patients
References:
Vardon VM, Blessed G. Confusion ratings and abbreviated mental test performance: A
comparison. Age Ageing. 1986; 15: 139-144.
18.03.04 The Set Test of Isaacs and Akhtar
Overview:
Isaacs and Akhtar developed a simple test to rapidly assess the mental functioning of an
elderly person. It can be used to monitor functioning over time. The authors were from
the Glasgow Royal Infirmary.
Instructions:
(1) The person is asked to name items from 4 different categories.
(2) The test is presented as a challenge rather than as a threat.
(3) Neither the examiner nor bystanders should help the patient with answers.
(4) The examiner can repeat the instructions as often as needed.
(5) There is no time limit.
(6) This is a verbal test not suitable to deaf or aphasic subjects.
Endpoints: one of the following
(1) The person is able to name a total of 10 or more items.
(2) The patient is unable to think of any new items.
(3) The patient repeats items, with no new additions.
Categories:
(1) colors
(2) animals
(3) fruits
(4) towns
subscore for each categories =
= MIN(10, number of items mentioned)
total score =
= SUM(points for all 4 categories)

Interpretation:
minimum score: 0
maximum score: 40
The higher the score, the better the mental status of the patient.
Group of Normal
Adults
males 65 74 years
males >= 75 years
females 65 74
females >= 75 years

Mean Total Score


34.3
27.3
32.4
29.4

Standard
Deviation (SD)
5.1
7.6
7.7
8.6

Mean - 2.0 SD
24
12
17
12

where:
Decimal fractions are seen in the mean scores and standard deviations, but test results
are only in whole numbers.
A score < (mean (2 * SD)) would be below the normal range (assuming a Gaussian
distribution in mental functioning).
Performance:
The test does not appear to be seriously affected by educational or cultural factors.
Subjects found the test acceptable.
The test avoids fatiguing the patient.
Its performance compared favorably with other measures of mental functioning in the
elderly.
References:
Isaacs B, Akhtar AJ. The set test: A rapid test of mental function in old people. Age and
Ageing. 1972; 1: 222-226.
18.04 Evaluation of Depression
18.04.01 Geriatric Depression Scale
Overview:
The Geriatric Depression Scale can be used to evaluate the elderly individual for
depressive symptoms. It is a self-rating instrument that is easy to answer and geared
towards the geriatric patient.

1
2
3

Choose the best answer for how you felt over


the past week.
Are you basically satisfied with your life?
Have you dropped many of your activities and
interests?
Do you feel that your life is empty?

Points for Response


Yes
No
0
1

1
0

4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Do you often get bored?


Are you hopeful about the future?
Are you bothered by thoughts you can't get out of
your head?
Are you in good spirits most of the time?
Are you afraid that something bad is going to
happen to you?
Do you feel happy most of the time?
Do you often feel helpless?
Do you often get restless and fidgety?
Do you prefer to stay at home, rather than going
out and doing new things?
Do you frequently worry about the future?
Do you feel you have more problems with memory
than most?
Do you think it is wonderful to be alive now?
Do you often feel downhearted and blue?
Do you feel pretty worthless the way you are now?
Do you worry a lot about the past?
Do yo find life very exciting?
Is it hard for you to get started on new projects?
Do you feel full of energy?
Do you feel that you situation is hopeless?
Do you think that most people are better off than
you are?
Do you frequently get upset over little things?
Do you frequently feel like crying?
Do you have trouble concentrating?
Do you enjoy getting up in the morning?
Do you prefer to avoid social gatherings?
Is it easy for you to make decisions?
Is you mind as clear as it used to be?

1
0
1

0
1
0

0
1

1
0

0
1
1
1

1
0
0
0

1
1

0
0

0
1
1
1
0
1
0
1
1

1
0
0
0
1
0
1
0
0

1
1
1
0
1
0
0

0
0
0
1
0
1
1

where
points are assigned for depressive responses
"No" answers considered depressive responses: questions 1, 5, 7, 9, 15, 19, 21, 27, 29,
30
"Yes" answers considered depressive responses: questions 2, 3, 4, 6, 8, 10, 11, 12, 13,
14, 16, 17, 18, 20, 22, 23, 24, 25, 26, 28
score =
= SUM (points for all 30 questions)
Interpretation

The results should be interpreted with discretion.


scores of 0-10 are not increased and are "normal" for the elderly
scores of 11-13 are borderline
scores of 14-30 are increased and associated with depression
References:
Brink TL, Yesavage JA, et al. Screening tests for geriatric depression. Clin Gerontologist.
1982; 1: 37-43.
Lachs MS, Feinstein AR, et al. A simple procedure for general screening of functional
disability in elderly patients. Ann Intern Med. 1990; 112: 699-706.
McDowel I, Newell C. Measuring Health - A Guide to Rating Scales and Questionnaires,
Second Edition. Oxford University Press. 1996. pages 259-263
Yesavage J, Brink TL, et al.. Development and validation of a geriatric depression scale. A
preliminary report. J Psychiatr Res. 1983; 17: 39-49.
18.04.02 CES-D Self-Report Depression Scale
Overview:
The Center for Epidemiologic Studies (CES) of the National Institute of Mental Health
was developed for research in the general population. It can be used to monitor a person
before, during and after intervention.
Responses are for how the person felt that way during the past week:
rarely or none of the time (less than 1 day)
some or a little of the time (1-2 days)
occasionally or a moderate amount of time (3-4 days)
most or all of the time (5-7 days)

1
2
3

4
5
6
7
8

During the past week:


I was bothered by things that
usually don't bother me.
I did not feel like eating; my
appetite was poor.
I felt that I could not shake off
the blues even with help from my
family or friends.
I felt that I was just as good as
other people.
I had trouble keeping my mind on
what I was doing.
I felt depressed.
I felt that everything I did was an
effort.
I felt hopeful about the future.

rare
0

some
1

moderate
2

mostly
3

0
0

1
1

2
2

3
3

9
10
11
12
13
14
15
16
17
18
19
20

I thought my life had been a


failure.
I felt fearful.
My sleep was restless.
I was happy.
I talked less than usual.
I felt lonely
People were unfriendly.
I enjoyed life.
I had crying spells.
I felt sad.
I felt that people dislike me.
I could not get "going.

0
0
3
0
0
0
3
0
0
0
0

1
1
2
1
1
1
2
1
1
1
1

2
2
1
2
2
2
1
2
2
2
2

3
3
0
3
3
3
0
3
3
3
3

where:
questions 4, 8, 12 and 16 were positive in content
score =
= SUM (points for all 20 questions)
Interpretation
minimum score: 0
maximum score: 60
a score > 16 was considered "at risk" for depression, although this seems set a bit low
no score was set to indicate depression, but the higher the score the more likely it would
be (> 40 was selected for the implementation).
References:
McDowel I, Newell C. Measuring Health - A Guide to Rating Scales and Questionnaires,
Second Edition. Oxford University Press. 1996. pages 254-259
Radloff LS. The CES-D scale: A self-report depression scale for research in the general
population. Appl Psychol Measure. 1977; 1: 385-401.
18.04.03 The Zung Self-Rating Depression Scale
Overview:
The Self-Rating Depression Scale of Zung is an instrument for assessing depression
simply and specifically, using traits found in the depressive disorders.
Questionnaire
20 questions consisting of 10 symptomatically negative and 10 symptomatically
positive questions
increased duration associated with high score: questions 1, 3, 4, 7, 8, 9, 10, 13, 15, 19
increased duration associated with low score: questions 2, 5, 6, 11, 12, 14, 16, 17, 18, 20

Questions

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

I fell down-hearted and blue.


Morning is when I feel the best.
I have crying spells or feel like it.
I have trouble sleeping at night.
I eat as much as I used to.
I still enjoy sex.
I notice that I am losing weight.
I have trouble with constipation.
My heart beats faster than usual.
I get tired for no reason.
My mind is as clear as it used to
be.
I find it easy to do the things I used
to.
I am restless and can't keep still.
I feel hopeful about the future.
I am more irritable than usual.
I find it easy to make decisions.
I feel that I am useful and needed.
My life is pretty full.
I feel that others would be better
off if I were dead.
I still enjoy the things I used to do.

a little
of the
time
1
4
1
1
4
4
1
1
1
1
4

some of
the time

1
4
1
4
4
4
1

2
3
2
3
3
3
2

3
2
3
2
2
2
3

4
1
4
1
1
1
4

2
3
2
2
3
3
2
2
2
2
3

good
most of
part of the time
the time
3
4
2
1
3
4
3
4
2
1
2
1
3
4
3
4
3
4
3
4
2
1

self-rated raw score =


= SUM(points for all 20 questions)
average score =
= (self-rated raw score) / 20
SDS index =
= (self-rated raw score) / 80
Interpretation:
minimum raw score 20
maximum raw score 80
minimum SDS index 0.25
maximum SDS index 1.0
index for normal, control population: 0.25-0.43
index for people admitted with depression, but discharged with other diagnoses: 0.380.71

index for people admitted and discharged with the diagnosis of depression: 0.63-0.90
References:
Carroll BJ, Fielding JM, et al. Depression rating scales. Arch Gen Psychiatry. 1973; 28:
361-366.
McDowel I, Newell C. Measuring Health - A Guide to Rating Scales and Questionnaires,
Second Edition. Oxford University Press. 1996. pages 249-254
Zung WW. A self-rating depression scale. Arch Gen Psychiat. 1965; 12: 63-70.
18.04.04 Beck Inventory for Measuring Depression
Overview:
The Inventory for Measuring Depression of Beck et al is an instrument to measure
behavioral manifestations of depression. It can be used over time to monitor symptoms
and to assess response to therapeutic interventions.
Depression Inventory
21 groups of statements are offered, with the subject selecting the one that best matches
his or her current state
each statement group corresponds to a specific behavioral manifestation
responses are scored 0-3, corresponding to no, mild, moderate or severe depressive
symptomatology in the response
if 2 or more responses are of the same magnitude, they are designated by letters (a, b or
c)
Administration
A copy of the questionnaire is completed by trained interviewer.
The subject has another copy available to read from during the interview.
This could also be administered as a self-reporting instrument.
Inventory
A (Mood)
[0] I do not feel sad.
[1] I feel blue or sad.
[2a] I am blue or sad all the time and I can't snap out of it.
[2b] I am so sad or unhappy that it is very painful.
[3] I am so sad or unhappy that I can't stand it.
B (Pessimism)
[0] I am not particularly pessimistic or discouraged about the future.
[1] I feel discouraged about the future.
[2a] I feel I have nothing to look forward to.
[2b] I feel that I won't ever get over my troubles.
[3] I feel that the future is hopeless and that things cannot improve.

C (Sense of Failure)
[0] I do not feel like a failure.
[1] I feel I have failed more than the average person.
[2a] I feel I have accomplished very little that is worthwhile or that means anything.
[2b] As I look back on my life all I can see is a lot of failures.
[3] I feel I am a complete failure as a person.
D (Lack of Satisfaction)
[0] I am not particularly dissatisfied.
[1a] I feel bored most of the time.
[1b] I don't enjoy things the way I used to.
[2] I don't get satisfaction out of anything any more.
[3] I am dissatisfied with everything.
E (Guilty Feelings)
[0] I don't feel particularly guilty.
[1] I feel bad or unworthy a good part of the time.
[2a] I feel quite guilty.
[2b] I feel bad or unworthy practi-cally all the time now.
[3] I feel as though I am very bad or worthless.
F (Sense of Punishment)
[0] I don't feel I am being punished.
[1] I have a feeling that something bad may happen to me.
[2] I feel I am being punished or will be punished.
[3a] I feel I deserve to be punished.
[3b] I want to be punished.
G (Self Hate)
[0] I don't feel disappointed in myself.
[1a] I am disappointed in myself.
[1b] I don't like myself.
[2] I disgusted with myself.
[3] I hate myself.
H (Self Accusations)
[0] I don't feel I am any worse than anybody else.
[1] I am very critical of myself for my weaknesses or mistakes.
[2a] I blame myself for everything that goes wrong.
[2b] I feel I have many bad faults.
I (Self-punitive Wishes)
[0] I don't have any thoughts of harming myself.
[1] I have thoughts of harming myself but I would not carry them out.
[2a] I feel I would be better off dead.
[2b] I have definite plans about committing suicide.

[2c] I feel my family would be better off if I were dead.


[3] I would kill myself if I could.
J (Crying Spells)
[0] I don't cry any more than usual.
[1] I cry more now than I used to.
[2] I cry all the time now. I can't stop it.
[3] I used to be able to cry but now I can't cry at all even though I want to.
K (Irritability)
[0] I am no more irritated now than I ever am.
[1] I get annoyed or irritated more easily than I used to.
[2] I feel irritated all the time.
[3] I don't get irritated at all at the things that used to irritate me.
L (Social Withdrawal)
[0] I have not lost interest in other people.
[1] I am less interested in other people now than I used to be.
[2] I have lost most of my interest in other people and have little feeling for them.
[3] I have lost all of my interest in other people and don't care about them at all.
M (Indecisiveness)
[0] I make decisions about as well as ever.
[1] I am less sure of myself now and try to put off making decisions.
[2] I can't make decisions any more without help.
[3] I can't make any decisions at all any more.
N (Body Image)
[0] I don't feel I look any worse than I used to.
[1] I am worried that I am looking old or unattractive.
[2] I feel that there are permanent changes in my appearance and they make me look
unattractive.
[3] I feel that I am ugly or repulsive looking.
O (Work Inhibition)
[0] I can work about as well as before.
[1a] It takes extra effort to get started at doing something.
[1b] I don't work as well as I used to.
[2] I have to push myself very hard to do anything.
[3] I can't do any work at all.
P (Sleep Distrubance)
[0] I can sleep as well as usual.
[1] I wake up more tired in the morn-ing than I used to.
[2] I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
[3] I wake up early every day and can;t get more than 5 hours sleep.

Q (Fatigability)
[0] I don't get any more tired than usual.
[1] I get tired more easily than I used to.
[2] I get tired from doing anything.
[3] I get too tired to do anything.
R (Loss of Appetite)
[0] My appetite is no worse than usual.
[1] My appetite is not as good as it used to be.
[2] My appetite is much worse now.
[3] I have no appetite at all any more.
S (Weight Loss)
[0] I haven't lost much weight, if any, lately.
[1] I have lost more than 5 pounds.
[2] I have lost more than 10 pounds.
[3] I have lost more than 15 pounds.
T (Somatic Preoccupations)
[0] I am no more concerned abut my health than usual.
[1] I am concerned about aches and pains or upset stomach or constipation or other
unpleasant feelings in my body.
[2] I am so concerned with how I feel that it's hard to think of much else.
[3] I am completely absorbed in what I feel.
U (Loss of Libido)
[0] I have not noticed any recent change in my interest in sex.
[1] I am less interested in sex than I used to be.
[2] I am much less interested in sex now.
[3] I have lost interest in sex completely.
Interpretation
I was unable to find in the paper the precise way that a score was derived using the
values for each symptom group.
A reference is made to the total inventory score, presumably derived by summating the
points for all 21 questions; this would give a minimum score of 0 and a maximum of
62.
An option not mentioned in the paper is to take the mean response value and to
interpret it over the range of 0 to 3 (no to severe depression).
References:
Beck AT, Ward CH, et al. An inventory for measuring depression. Arch Gen Psychiatry.
1961; 4 :561-571.
McDowel I, Newell C. Measuring Health - A Guide to Rating Scales and Questionnaires,
Second Edition. Oxford University Press. 1996. pages 242-249

18.04.05 The Brief Depression Scale of Koenig et al


Overview:
Depression is common yet may be missed in primary care settings. A brief questionairre
developed by Koenig et al requires simple yes or no responses and is quickly given. This
makes it attractive for emergency situations, when dealing with the medically ill, or with
the elderly.
Components: 11 questions
(1) depressed mood: 1, 3, 7, 8
(2) DSM-III-R diagnostic criteria for major depression: 2, 5, 6, 10, 11
(3) 2 items on helplessness-hopelessness and memory: 4, 9

1
2
3
4
5
6
7
8
9
10
11

Choose the best answer for hour have felt over the
past week:
Do you often get bored?
Do you often get restless or fidgety?
Do you feel in good spirits?
Do you feel you have more problems with memory than
most?
Can you concentrate easily when reading the papers?
Do you prefer to avoid social gatherings?
Do you often feel downhearted and blue?
Do you feel happy most of the time?
Do you often feel helpless?
Do you feel worthless and ashamed about yourself?
Do you often wish you were dead?

Yes

No

x
x
x
x
x
x
x
x
x
x
x

Responses associated with depression are marked with an "x" in the table above.
score =
= SUM(responses given which are associated with depression)
Interpretation
minimum score: 0
maximum score: 11
Cutoffs for detection of depression:
>= 3 (Koenig et al): sensitivity 83% and specificity 77%
>= 4 (Gartner et al, as reported in Meldon et al): sensitivity 100% and specificity 85%
References:
Koenig HG, Cohen HJ, et al. A brief depression scale for use in the medically ill.
International J Psychiatry Med. 1992; 22: 183-195.

Meldon SW, Emerman CL, et al. Depression in geriatric ED patients: Prevalence and
recognition. Ann Emerg Med. 1997; 30: 141-145.
18.04.06 The Edinburgh Postnatal Depression Scale
Overview:
The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-rating instrument for
depression in a woman who has recently been pregant. It was developed at the University
of Edinburgh in Scotland.
Instructions:
As you have recently had a baby, we would like to know how you are feeling. Please
mark (underline) the answer which comes closest to how you have felt IN THE PAST 7
DAYS, not juse how you feel today.
Questions: During the past 7 days
(1) I have been able to laugh and see the funny side of things.
Response
as much as I always could
not quite so much now
definitely not so much now
not at all

Points
0
1
2
3

(2) I have looked forward with enjoyment to things.


Response
as much as I ever did
rather less than I used to
definitely less than I used to
hardly at all

Points
0
1
2
3

(3) I have blamed myself unnecessarily when things went wrong.


Response
yes, most of the time
yes, some of the time
not very often
no, never

Points
3
2
1
0

(4) I have been anxious or worried for no good reason.


Response

Points

no, not at all


hardly ever
yes, sometimes
yes, very often

0
1
2
3

(5) I have felt scared or panicky for no very good reason.


Response
yes, quite a lot
yes, sometimes
no, not very much
no, not at all

Points
3
2
1
0

(6) Things have been getting on top of me.


Response
yes, most of the time I haven't been able to cope at all
yes, sometimes I haven't been coping as well as usual.
no, most of the time I have coped quite well.
no, I have been coping as well as ever
(7) I have been so unhappy that I have had difficulty sleeping.
Response
yes, most of the time
yes, quite often
not very often
not at all

Points
3
2
1
0

(8) I have felt sad or miserable.


Response
yes, most of the time
yes, quite often
not very often
no, not at all

Points
3
2
1
0

(9) I have been so unhappy that I have been crying.


Response
yes, most of the time
yes, quite often
only occasionally

Points
3
2
1

Points
3
2
1
0

no, never

(10) The thought of harming myself has occurred to me.


Response
yes, quite often
sometimes
hardly ever
never

Points
3
2
1
0

score =
= SUM(points for all 10 items)
Interpretation:
minimum score: 0
maximum score: 30
The higher the score, the more severe the depressive symptoms.
A threshold score of 12/13 identified all of the patients with definite major depression
and most the patients with pobable major depression. This threshold had false
negatives for minor depression and false positives for normal women.
References:
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the
10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987; 150: 782-786.
Glaze R, Cox JL. Validation of a computerized version of the 10-item (self-rating)
Edinburgh Postnatal depression scale. J Affective Disorders. 1991; 22: 73-77.
Murray L, Caothers AD. The validation of the Edinburgh Post-natal Depression Scale on
a community sample. Br J Psychiatry. 1990; 157: 288-290.
18.04.07 The Harvard Department of Psychiatry and National Depression
Screening Day Scale (HANDS)
Overview:
The Harvard Department of Psychiatry and National Depression Screening Day Scale
(HANDS) is an easy-to-use screening tool of 10 questions to identify patients with
symptoms of recent depression. It is designed to take minimal physician time; it can be
filled out by the patient in the waiting room and scored by office staff. Screening for
Mential Health , Inc is a nonprofit organization which sponsors the annual National
Depression Screening Day (NDSD).
NOTE: The scale is under copyright to the President and Fellows of Harvard College and
Screening for Mental Health, Inc. It should be used in conjunction with programs of
Screening for Mental Health only. Duplication or use without prior permission of figure
on page 2695 is prohibited. For permission to use, contact: Screening for Mental Health,

One Washington Street, Suite 304, Wellesley Hills, MA. 02481-1706, Attn: JAMAHANDS permission.
Over the past 2 weeks, how often have
you?
been feeling low on energy, slowed down?

been blaming yourself for things?

had poor appetite?

had difficulty falling asleep, staying


asleep?

been feeling hopeless about the future?

been feeling blue?

been feeling no interest in things?

had feelings of worthlessness?

Response

Points

none
little of the time
some of the time
most of the time
all of the time
none
little of the time
some of the time
most of the time
all of the time
none
little of the time
some of the time
most of the time
all of the time
none

0
0
1
2
3
0
0
1
2
3
0
0
1
2
3
0

little of the time


some of the time
most of the time
all of the time
none
little of the time
some of the time
most of the time
all of the time
none
little of the time
some of the time
most of the time
all of the time
none
little of the time
some of the time
most of the time
all of the time
none
little of the time

0
1
2
3
0
0
1
2
3
0
0
1
2
3
0
0
1
2
3
0
0

thought about or wanted to commit


suicide?

had difficulty in concentrating or making


decisions?

some of the time


most of the time
all of the time
none

1
2
3
0

little of the time


some of the time
most of the time
all of the time
none

0
1
2
3
0

little of the time


some of the time
most of the time
all of the time

0
1
2
3

total score =
= SUM(points for all 10 questions)
Interpretation:
minimum score: 0
maximum scoe: 30
The higher the score, the greater the risk for a major depressive episode.
Total Score
08

9 16

17 - 30

Interpretation
Symptoms are not consistent with a major depressive
episode. Presence of a major depressive episode is
unlikely.
Symptoms are consistent with a major depressive
episode. Presence of a major depressive episode is likely.
In a self-selected population it is possible that the person
instead suffers from a DSM-IV anxiety disorder.
Symptoms are strongly consistent with criteria for a
major depessive episode. Presence of major depressive
disorder is very likely.

References:
Jacobs DG. A 52-year-old suicidal man. JAMA. 2000; 283: 2693-2699.
18.04.08 The Hopelessness Scale of Beck et al
Overview:
The Hopelessness Scale is a self-reported measure of pessimism and hopelessness. This
can help identify patients who are likely to die if suicide is attempted. It also correlates

with level of depression and sociopathy. The authors are from the University of
Pennsylvania and Philadelphia General Hospital.
Statements:
(1) I look forward to the future with hope and enthusiasm.
(2) I might as well give up because I can't make things better for myself.
(3) When things are going badly, I am helped by knowing they can't stay that way
forever.
(4) I can't imagine what my life would be like in 10 years.
(5) I have enough time to accomplish the things I most want to do.
(6) In the future, I expect to succeed in what concerns me most.
(7) My future seems dark to me.
(8) I expect to get more of the good things in life than the average person.
(9) I just don't get the breaks, and there's no reason to believe I will in the future.
(10) My past experiences have prepared me well for my future.
(11) All I can see ahead of me is unpleasantness rather than pleasantness.
(12) I don't expect to get what I really want.
(13) When I look ahead to the future, I expect I will be happier than I am now.
(14) Things just won't work out the way I want them to.
(15) I have great faith in the future.
(16) I never get what I want so it's foolish to want anything.
(17) It is very unlikely that I will get any real satisfaction in the future.
(18) The future seems vague and uncertain to me.
(19) I can look forward to more good times than bad times.
(20) There's no use in really trying to get anything I want because I probably won't get it.
Scoring:
1 point if "True", 0 points if "False" (11) : 2, 4, 7, 9, 11, 12, 14, 16, 17, 18, 20
1 point if "False", 0 points if "True" (9): 1, 3, 5, 6, 8, 10, 13, 15, 19
hopelessness scale =
= SUM(points for all 20 statements)
feelings about the future subscore =
= SUM(points for 1, 6, 13, 15, 19)
loss of motivation subscore =
= SUM(points for 2, 3, 9, 11, 12, 16, 17, 20)
future expectations subscore =
= SUM(points for 4, 7, 8, 14, 18)
where:
Statements 5 and 10 are not included in the subscores.
Interpretation:

minimum total score: 0


maximum total score: 20
The higher the score, the greater the sense of hopelessness.
Patients who eventually died by suicide had higher scores than those who did not die.
In the series reported in 1985, 91% of people who died by suicide had a score >= 10,
while only 9% had a score <= 9.
References:
Beck AT, Weissman A, et al. The measurement of pessimism: The Hopelessness Scale. J
Consult Clinical Psychology. 1974; 42: 861-865.
Beck AT, Steer RA, et al. Hopelessness and eventual suicide: A 10-year prospective
study of patients hospitalized with suicidal ideation. Am J Psychiatry. 1985; 142:
559-563.
18.04.09 Indications to Screen a Patient for Depression
Overview:
Depression is a common condition. The clinician should consider the possibility of
depression if certain clinical findings are noted during the clinical interview.
A patient should be screened for depression if he or she:
(1) has experienced a recent loss
(2) is undergoing severe stress
(3) reports vague somatic symptoms (insomnia, headaches, stomachaches)
(4) express any of the somatic or emotional symptoms of depression (problems with
sleeping, eating, sexual functioning, etc.; loss of interests; feeling blue, etc.)
(5) has a history of alcohol abuse or other self-medicating behavior
(6) has a history of self-destructive behavior
(7) is currently taking a medication associated with depression (antihypertensive,
hormones, anticonvulsant, levodopa, beta-blockers, histamine-2 receptor blockers,
etc.)
(8) is suffering from a major medical illness such as stroke, diabetes or cancer
(9) is a woman in the postpartum period
(10) has been previously been diagnosed as being depressed
(11) has a family history of depression, suicide or mental illness
References:
Jacobs DG. A 52-year-old suicidal man. JAMA. 2000; 283: 2693-2699.
18.04.10 The Montgomery-Asberg Depression Rating Scale (MADRS)
Overview:
Montgomery and Asberg developed a depression rating scale that is simpler than the
Hamilton Depression Scale yet responsive to change in the patient's state. This can be
used to monitor a patient's state over time. The authors are from Guy's Hospital in
London and the Karolinska Institute in Stockholm.

Item list:
(1) apparent sadness
(2) reported sadness
(3) inner tension
(4) reduced sleep
(5) reduced appetite
(6) concentration difficulties
(7) lassitude
(8) inability to feel
(9) pessimistic thoughts
(10) suicidal thoughts
Responses: from 0 (normal) to 6 (severe depression)
Statements are provided for 0, 2, 4, and 6.
1, 3 and 5 and in-between values.
(1) apparent sadness: despondency, gloom and despair that is more than just ordinary
transient low spirits
Response
no sadness
looks dispirited but does brighten up without difficulty
appears sad and unhappy most of the time
looks miserable all the time; extremely despondent

Points
0
2
4
6

(2) reported sadness: reports of depressed mood, regardless of whether it is reflected in


appearance or not. This includes low spiritis, despondency, or the feeling of being
beyond help and without hope. Rate according to intensity, duration, and the extent
to which the mood is reported to be influenced by events.
Response
occasional sadness in keeping with the circumstances
sad or low but brightens up without difficulty
pervasive feelings of sadness or gloominess. The mood is
still influenced by external circumstances.
continuous or unvarying sadness, misery or despondency

Points
0
2
4
6

(3) inner tension: feelings of ill-defined discomfort, edginess, inner turmoil, mental tension
mounting to either panic, dread or anguish. Rate according to intensity, frequency,
duration and the extent of reassurance called for.
Response
placid, with only fleeing inner tension
occasional feelings of edginess and ill-defined discomfort

Points
0
2

continuous feelings of inner tension or intermittent panic


which the patient can only master with some difficulty
unrelenting dread or anguish; overwhelming panic

4
6

(4) reduced sleep: reduced duration or depth of sleep compared to the subject's own
normal pattern when well
Response
sleeps as usual
slight difficulty dropping off to sleep; slightly reduced,
light or fitful sleep
sleep reduced or brokedn by at least 2 hours
less than 2-3 hours of sleep

Points
0
2
4
6

(5) reduced appetite: loss of appetite compared with when well. There may be a loss of
desire for food or the need to force oneself to eat.
Response
normal or increased appetite
slightly reduced appetite
no appetites and food is tasteless
needs persuasion to eat at all

Points
0
2
4
6

(6) concentration difficulties: difficulties in collecting one's thoughts mounting to an


incapacitating lack of concentration. This is rated according to the intensity, frequency
and degree of incapacity produced.
Response
no difficulties with concentrating
occasional difficulties in collecting one's thoughts
difficulties in concentrating and sustaining thought which
reduces the ability to read or hold a conversation
unable to read or converse without great difficulty

Points
0
2
4
6

(7) lassitude: difficulty in getting started; slowness in initiating and performing everyday
activities
Response
hardly any difficulty in getting started; no sluggishness
difficulties in starting activities
difficulties in starting simple, routine activities which are
carried out with effort
complete lassitude; unalbe to do anything without help

Points
0
2
4
6

(8) inability to feel: reduced interest in the surroundings, or in activities that normally give
pleasure. The ability to react with adequate emotion to circumstances is reduced.
Response
normal interest in the surroundings and in other people
reduced ability to enjoy usual interests
loss of interest in the surroundings; loss of feelings for
friends and acquaintances
emotionally paralyzed; unable to feel anger, grief or
pleasure; complete or even painful failure to feel for close
relatives and friends

Points
0
2
4
6

(9) pessimistic thoughts: feelings of guilt, inferiority, self-reproach, sinfulness, remorse or


ruin.
Response
none
fluctuating ideas of failure, self-reproach or selfdepreciation
persistent self-accusation, or definite but still rational
ideas of guilt or sin; increasingly pessimistic about the
future
delusions of ruin, remorse or unredeemable sin; selfaccusations which are absurd and unshakable

Points
0
2
4

(10) suicidal thoughts: feeling that life is not worth living and/or that a natural death
would be welcome; presence of suicidial thoughts and the making of preparations for
suicide.
Response
enjoyes life or takes it as it comes
weary of life; only fleeting suicidal thoughts
probably better off dead; suicidal thoughts common, and
suicide is considered as a possible solution, but without
specific plans or intentions
explicit plans for suicide when there is an opportunity;
active preparations for suicide
total score =
= SUM(points for all 10 questions)
Interpretation:
minimum score: 0
maximum score: 60
The higher the score, the greater the degree of depression.

Points
0
2
4

Performance:
Maier et al found the MADRS that showed concurrent and external validity.
References:
Maier W, Philipp M, et al. Improving depression severity assessment I. Reliability,
internal validity and sensitivity to change of three observer depression scales. J
Psychiatr Res. 1988; 22: 3-12.
Maier W, Heuser I, et al. Improving depression severity assessment II. Content,
concurrent and external validity of three observer depression scales. J Psychiatr Res.
1988; 22: 13-19.
Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change.
British J Psychiatry. 1979; 134: 382-389 (Appendix pages 387-389).
18.05 Evaluation of the Obsessive-Compulsive Personality
18.05.01 Maudsley Obsessional-Compulsive Inventory
Overview:
The Maudsley Obsessional-Compulsive Inventory is an instrument for assessing the
existence and extent of different obsessional-compulsive complaints. It can be used over
time to determine response to therapeutic interventions.
Types of obessional-compulsive complaints:
major: checking and washing/cleaning compulsions
minor: slowness and doubting
Patient Instructions:
Please answer each question by putting a circle around the "True" or the"False" following
the question. There are no right or wrong answers, and no trick questions. Work quickly
and do not think too long about the exact meaning of the question.
Question
1
2
3
4
5

I avoid using public telephones because of


possible contamination.
I frequently get nasty thoughts and have difficulty
in getting rid of them.
I am more concerned than most people about
honesty.
I am often late because I can't seem to get through
everything on time.
I don't worry unduly about contamination if I
touch an animal.

True (with
loading value)
0.62

False

0.33 (checking)
-0.64 (slow)
0.60

0.41 (cleaning)
0.38 (slow)
-0.55

0
0
0

6
7
8

9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

I frequently have to check things (e.g., gas or water


taps, doors, etc.) several times.
I have a very strict conscience.
I find that almost every day I am upset by
unpleasant thoughts that come into my mind
against my will.
I do not worry unduly if I accidently bump into
somebody.
I usually have serious doubts about the simple
everyday things I do.
Neither of my parents was very strict during my
childhood.
I tend to get behind in my work because I repeat
things over and over again.
I use only an average amount of soap.
Some numbers are extremely unlucky.
I do not check letters over and over again before
posting them.
I do not take a long time to dress in the morning.
I am not excessively concerned about cleanliness.
One of my major problems is that I pay too much
attention to detail.
I can use well-kept toilets without any hesitation.
My major problem is repeated checking.
I am not unduly concerned about germs and
disease.
I do not tend to check things more than once.
I do not stick to a very strict routine when doing
ordinary things.
My hands do not feel dirty after touching money.
I do not usually count when doing a routine task.
I take a rather long time to complete my washing
in the morning.
I do not use a great deal of antiseptics.
I spend a lot of time every day checking things
over and over again.
Hanging and folding my clothes at night does not
take up a lot of time.
Even when I do something very carefully I often
feel that it is not quite right.

0.79

0.61
0.37 (checking)
-0.62 (slow)

0
0

-0.56

0.48

-0.50

0.51

-0.53
0.38
-0.63

0
0
0

-0.63
-0.72
0.44

0
0
0

-0.60
0.60
-0.70

0
0
0

-0.66
-0.58

0
0

-0.70
-0.34
0.43 (check)
0.43 (clean)
-0.53
0.62

0
0
0

-0.52

0.53

checking component: questions 2, 6, 8, 14, 15, 20, 22, 26, 28


cleaning/washing component: questions 1, 4, 5, 9, 13, 17, 19, 21, 24, 26, 27

0
0

slowness component: questions 2, 4, 8, 16, 23, 25, 29


doubting component: questions 3, 7, 10, 11, 12, 18, 30
questions in 2 components:
2 (checking, slowness), 4 (cleaning, slowness), 8 (checking, slowness), 26 (checking,
cleaning)
I am not sure why questions 2 and 8 are given non-obsessional weightings (negative
values) for the slowness subcomponent
Scoring
The simple method offered is to total the number of questions which are answered in the
obsessional direction.
Consistency check
same answers expected: 2 and 8, 3 and 7, 10 and 12, 17 and 21
different answers expected: 6 and 22, 16 and 26
if 1 point is assigned for each answer expected (4 same, 2 different), then maximum
score is 6 and minimum 0
random answers would give a score of 3
consistency scores of 3 or less indicate suspect results
In addition, a check was added to the spreadsheet looking for all true or all false answers,
as this would not be detected by the consistency check.
References:
Hodgson RJ, Rachman S. Obsessional-compulsive complaints. Behav Res & Therapy.
1977; 15: 389-395.
18.05.02 Lynfield Obsessional-Complusive Questionnaires
Overview:
The Lynfield Obsessional-Compulsive questionnaires measure symptoms in obsessional
disorders. They are derived from the Leyton Obsessional Inventory, which had the
disadvantage of taking a relatively long time to administer. The questionnaires can be used
to monitor response to treatments.
There are 2 questionnaires which use the same questions, but differ in the responses.
These are designed to measure either the resistance of the patient to the symptoms, or the
interference with other activities that the symptoms cause.
Instructions:
Please read the following questions carefully and answer each one by circling the letter
which applies particularly to you. Be sure to answer each question and circle only one
letter for each group. Answer the questions quickly according to how you feel about them

at the present time. Do not hesitate too long as it is your first impressions that are
required.
Questions
Are you very systematic and methodical in your daily life?
Do you regard cleanliness as a virtue in itself?
Does your stock of supplies, at home or at work, get large because you find yourself
ordering more than you can actually use?
Do you always fail to explain things properly, in spite of having planned beforehand
exactly what to say?
Do you feel unsettled or guilty if you haven't been able do do something exactly as you
would like?
Even when you have done something carefully, do you often feel that it is somehow not
quite right or complete?
Are you ever over-conscientious or very strict with yourself?
Do you ever get behind with your work because you have to do something over again
several times?
Do you ever have to do things over again a certain number of times before they seem quite
right?
Do you get a bit upset if you cannot do your work at set times or in a certain order?
Do you dislike having a room untidy or not quite clean for even a short time?
Are you very strict about the house always being kept very clean and tidy?
Do you take care that the clothes you are wearing are always clean and neat, whatever
you are doing?
Are you fussy about keeping your hands clean?
Do you ever have to go back and check doors, cupboards or windows to make sure that
they are really shut?
Do you ever have to check gas or water taps or light switches after you have already
turned them off?

Do you often have to check things several times?


Do you ever have a persistent imagination that your children or other members of your
family might be having an accident or that something might have happened to them?
Do unpleasant or frightening thoughts or words ever keep going over and over in your
mind?
Are you often inwardly compelled to do certain things even though your reason tells you
it is not necessary?
Responses for Each Question
Resistance Format
No, not at all.
Yes, but only to a reasonable
degree
Yes, it's just a habit.
Yes, and I sometimes try to
stop it.
Yes, and I always try very hard
to stop it.

Interference Format
No, not at all.
Yes, but I don't waste time over
it.
Yes, and I do waste a little time
over it.
Yes, and I waste more than a
little time over it.
Yes, and it wastes a great deal of
my time.

Points
0
1
2
3
4

Interpretation
minimum score 0
maximum score 80
References:
Allen JJ, Tune GS. The Lynfield Obsessional/Compulsive Questionnaires. Scottish Med
J. 1975; 20: 21-24.
18.06 Anxiety Disorders
18.06.01 Habits of Nervous Tension
Overview:
The Habits of Nervous Tension is a self-reporting instrument for how a person reacts to
stress, and may predict the risk for development of future health problems.
Instructions to Person:
Whenever you find yourself in situations of undue pressure or stress, how do you
usually react? (Underline all reactions which are characteristic of you.)
Briefly describe your chief reactions to pressure or stress and the situations in which
they most commonly occur (competitions, examinations, family situations, etc.)

Item
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Exhaustion or excessive fatigue.


Exhilaration.
Depressed feelings.
Uneasy or anxious feelings (sighing, tight feelings in throat
or chest, dry mouth, clammy hands, etc.)
General tension ("keyed up" feelings - difficulty in
becoming relaxed).
Increased activity.
Decreased activity.
An increased urge to sleep.
Increased difficulty in sleeping.
Increased urge to eat.
Loss of appetite.
Nausea.
Vomiting.
DIarrhoea
Constipation.
Urinary frequency.
Tremulousness or shakiness.
Anger (expressed) (concealed)
Gripe sessions.
Concern about your physical health.
A tendency to check and recheck your work to assure
yourself of accuracy.
An urge to confide and seek advice or reassurance.
An urge to be by yourself and get away from it all.
Irritability with concern as to who is to blame.
Philisophic effort with no reactions out of the ordinary.

Associated
Scale
depression
depression
anxiety
anxiety

depression
depression
anxiety
anxiety
anxiety

anxiety
anger
anger
depression

anxiety
depression
anger

Scoring
total number of all items indicated
the number of items in each of the 3 subscales: depression (6), anger (3) and anxiety (7)
Interpretation
Persons who showed a suboptimal response to stress had a higher incidence of coronary
artery disease, mental illness, and suicide.
References:
Rollman BL, Mead LA, et al. Medical specialty and the incidence of divorce. N Engl J
Med. 1997; 336: 800-803.

Thomas CB. Suicide amoung us: II. Habits of Nervous Tension as potential predictors.
Johns Hopkins Med J. 1971; 129: 190-201.
Thomas CB. Precursors of premature disease and death. Ann Intern Med. 1976; 85: 653658.
Thomas CB, McCabe OL. Precursors of premature disease and death: Habits of nervous
tension. Johns Hopkins Med J. 1980; 147: 137-145.
18.06.02 The Anxiety Status Inventory (ASI) of Zung
Overview:
The Anxiety Status Inventory (ASI) was developed by Zung as a rting instrument for
anxiety disorders. 20 affective and somatic symptoms associated with anxiety are graded
by an observer based on patient interview.
Affective and Somatic Symptoms
of Anxiety
anxiousness
fear
panic
mental disintegration
apprehension
tremors
body aches and pains
easy fatiguability, weakness
restlessness
palpitation
dizziness
faintness
dyspnea
paresthesias
nausea and vomiting
urinary frequency
sweating
face flushing

Interview Guide
Do you feel nervous and anxious?
Have you ever felt afraid?
How easily do you get upset? Ever have panic
spells or feel like it?
Do you ever feel like you are falling apart? Going
to pieces?
Have you ever felt uneasy? or that something
terrible was going to happen?
Have you had times when you felt yourself
trembling? shaking?
Do you have heaches? neck or back pains?
How easily do you get tired? Ever have spells of
weakness?
Do you find yourself restless and can't sit still?
Have you ever felt that your heart was running
away?
Do you have dizzy spells?
Do you have fainting spells? or feel like it?
Ever have trouble with your breathing?
Ever have feelings of numbness and tingling in
your fingertips? or around your mouth?
Do you ever feel sick to your stomach or feel like
vomiting?
How often do you need to empty your bladder?
Do you ever get wet, clammy hands?
Do you ever feel your face getting hot and
blushing?

insomnia
nightmares

How have you been sleeping? (in implementation:


Do you have problems sleeping?)
Do you have dreams that scare you?

Severity of observed or reported responses


none: 1
mild: 2
moderate: 3
severe: 4
Interpretation
minimum severity score: 20
maximum severity score: 80
The higher the score, the greater the symptoms associated with anxiety.
The ASI index converts the raw score by dividing the raw score by 80, then multiplying
by 100.
References:
Zung WWK. A rating instrument for anxiety disorders. Psychosomatics. 1971; 12: 371379.
18.06.03 The Self-rating Anxiety Scale (SAS) of Zung
Overview:
The Self-rating Anxiety Scale (SAS) was developed by Zung as a self-reporting
instrument for patients being evaluated for anxiety-associated symptoms. The patient
answers 20 questions related to the frequency of various symptoms.
Statements
(1) I feel more nervous and anxious than usual.
(2) I feel afraid for no reason at all.
(3) I get upset easily or feel panicky.
(4) I feel like I'm falling apart and going to pieces.
(5) I feel that everything is all right and nothing bad will happen
(6) My arms and legs shake and tremble.
(7) I am bothered by headaches, neck and back pain.
(8) I feel weak and get tired easily.
(9) I feel calm and can sit still easily.
(10) I can feel my heart beating fast.
(11) I am bothered by dizzy spells.
(12) I have fainting spells or feel like it.
(13) I can breathe in and out easily.
(14) I get feelings of numbness and tingling in my fingers and toes.
(15) I am bothered by stomaches or indigestion.
(16) I have to empty my bladder often.

(17) My hands are usually dry and warm.


(18) My face gets hot and blushes.
(19) I fall asleep easily and get a good night's rest.
(20) I have nightmares.
Directionality of responses
Increasing anxiety: 1, 2, 3, 4, 6, 7, 8, 10, 11, 12, 14, 15, 16, 18, 20
Decreasing anxiety (reverse direction): 5, 9, 13, 17, 19
Responses and point assignment
none or a little of the time: 1
some of the time: 2
a good part of the time: 3
most or all of the time: 4
Interpretation:
minimum response: 20
maximum response: 80
The higher the score, the greater the symptoms associated with anxiety.
The SAS index converts the raw score by dividing the raw score by 80, then multiplying
by 100.
References:
Zung WWK. A rating instrument for anxiety disorders. Psychosomatics. 1971; 12: 371379.
18.06.04 The Hospital Anxiety and Depression Scale (HAD Scale)
Overview:
The Hospital Anxiety and Depression (HAD) Scale is a self-assessment instrument for
detecting anxiety and depression in medical outpatients. The authors are from St James'
University Hospital at Leeds, England.
number of statements: 14 (7 anxiety, 7 depression)
Instructions:
Doctors are aware that emotions play an important part in most illnesses. If your doctor
knows about these feelings s/he will be able to help you more. This questionnaire is
designed to help your doctor to know how you feel. Read each item and indicate the reply
that comes closest to how you have been feeling in the past week. Don't take too long
over your replies; your immediate reaction to each item will probably be more accurate
than a long thought out response.
Statement
I feel tense or "wound up"

Response
most of the time

Points
3 [A]

I still enjoy the things I used to


enjoy

I get a sort of frightened feeling as


if something awful is about to
happen

I can laugh and see the funny side


of things

Worrying thoughts go through my


mind

I feel cheerful

I can sit at ease and feel relaxed

I feel as if I am slowed down

I get a sort of frightened feeling,


like "butterflies" in the stomach

I have lost interest in my


appearance

a lot of the time


from time to time, occasionally
not at all
definitely as much

2
1
0
0 [D]

not quite as much


only a little
hardly at all
very definitely and quite badly

1
2
3
3 [A]

yes, but not too badly


a little, but it doesn't worry me
not at all
as much as I always could

2
1
0
0 [D]

not quite so much now


definitely not so much now
not at all
a great deal of the time

1
2
3
3 [A]

a lot of the time


from time to time but not too often
only occasionally
not at all
not often
sometimes
most of the time
definitely
usually
not often
not at all
nearly all the time
very often
sometimes
not at all
not at all

2
1
0
3 [D]
2
1
0
0 [A]
1
2
3
3 [D]
2
1
0
0 [A]

occasionally
quite often
very often
definitely

1
2
3
3 [D]

I feel restless as if I have to be on


the move

I look forward with enjoyment to


thigns

I get sudden feelings of panic

I can enjoy a good book or radio or


TV programme

I don't take so much care as I


should
I may not take quite as much care
I take just as much care as ever
very much indeed

1
0
3 [A]

quite a lot
not very much
not at all
as much as ever I did

2
1
0
0 [D]

rather less than I used to


definitely less than I used to
hardly at all
very often indeed
quite often
not very often
not at all
often

1
2
3
3 [A]
2
1
0
0 [D]

sometimes
not often
very seldom

1
2
3

anxiety subscore =
= SUM(points for the 7 anxiety items)
depression subscore =
= SUM(points for the 7 depression items)
Interpretation:
minimum subscore: 0
maximum subscore: 21
Subscore
<= 7
8 10
>= 11

Anxiety or Depression
not present
doubtful
definite

References:
Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr.
Scand. 1983; 67: 361-370.
18.07 Psychological Response to Traumatic Events

18.07.01 The Revised Impact of Event Scale


Overview:
The revised Impact of Event Scale is a self-reporting instrument derived from statements
used to describe episodes of distress by persons who experienced recent serious life
changes. This can be used to assess persons with the post-traumatic stress disorder.
Instructions:
On <date> you experienced <life event>. Below is a list of comments made by people
after stressful life events. Please check each item, indicating how frequently these
comments were true for you DURING THE PAST SEVEN DAYS. If they did not occur
during that time, please mark the "not at all" column.
List of comments
(1) I thought about it when I didn't mean to.
(2) I avoided letting myself get upset when I thought about it or was reminded about it.
(3) I tried to remove it from memory.
(4) I had trouble falling asleep or staying asleep, because of pictures or thoughts about it
that came into my mind.
(5) I had waves of strong feelings about it.
(6) I had dreams about it.
(7) I stayed away from reminders of it.
(8) I felt as if it hadn't happened or it wasn't real.
(9) I tried not to talk about it.
(10) Pictures about it popped into my mind.
(11) Other things kept making me think about it.
(12) I was aware that I still had a lot of feelings about it, but I didn't deal with them.
(13) I treid not to think about it.
(14) Any reminder brought back feelings about it.
(15) My feelings about it were kind of numb.

Frequency Responses
not at all
rarely
sometimes
often

Points
0
1
3
5

Groupings:
intrusion subset: 1, 4, 5, 6, 10, 11, 14
avoidance subset: 2, 3, 7, 8, 9, 12, 13, 15
instrusion subscale =
= SUM (points for comments 1, 4, 5, 6, 10, 11, 14)

avoidance subscale =
= SUM (points for comments 2, 3, 7, 8, 9, 12, 13, 15)
total impact of event scale =
= (intrusion subscale) + (avoidance subscale)
Interpretation
minimum total score: 0
maximum total score: 75
The higher the score the greater the impact of the event.
High scores on the impact of event scale after an event or injury is predictive of
psychiatric morbidity and the post-traumatic stress disorder at 6 months after the
event.
References
Feinstein A, Dolan R. Predictors of post-traumatic stress disorder following physical
trauma: an examination of the stressor criterion. Psychological Med. 1991; 21: 85-91.
Horowitz M, Wilner N, Alvarez W. Impact of event scale: A measure of subjective
stress. Psychosomatic Med. 1979; 41: 209-218.
Zilberg NJ, Weiss DS, et al. Impact of event scale: A cross-validation study and some
empiric evidence supporting a conceptual model of stress response syndromes. J
Consult Clin Psychol. 1982; 50: 407-414.
18.07.02 Acute Stress Disorder
Overview:
The acute stress disorder is an axiety disorder that follows a traumatic event and which is
not caused by another condition. It shares features with the acute posttraumatic stress
disorder. Precipitating events can range from a serious accident to the diagnosis of cancer.
Criteria for the Acute Stress Disorder
(1) The person has been exposed to a traumatic event with BOTH of the following:
(a) The person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, or a threat to the physical
integrity of self or others.
(b) The person's response involved intense fear, helplessness or horror.
(2) The person has 3 or more of the following dissociative symptoms either while
experiencing or after experiencing the distressing event:
(a) subjective sense of numbing, detachment or absence of emotional responsiveness
(b) a reduction in awareness of his or her surroundings ("being in a daze")
(c) derealization
(d) depersonalization
(e) dissociative amnesia (unable to recall an important aspect of the trauma)

(3) The traumatic event is persistently reexperienced in at least one of the following
ways:
(a) recurrent images, thoughts, dreams illusions, flashback episodes
(b) sense of reliving the experience
(c) distress on exposure to reminders of the traumatic event
(4) Marked avoidance of stimuli that arouse recollections of the trauma, including
thoughts, feelings, conversations, activities, places, people.
(5) Marked symptoms of anxiety or increased arousal: difficulty sleeping, irritability,
poor concentration, hypervigilance, exaggerated startle response, motor restlessness.
(6) The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or impairs the ability of the
person to pursue some necessary task.
(7) The disturbance lasts
(a) a minimum of 2 days
(b) a maximum of 4 weeks
(c) occurs within 4 weeks of the traumatic event
(8) The disturbance is not due to
(a) a direct physiological effect of a drug or medication or abused substance
(b) a concurrent medical condition
(c) a brief psychotic disorder
(d) an exacerbation of a preexisting Axis I or Axis II disorder
References
American Psychiatric Association. Diagnostic Criteria from DSM-IV. 1994. pages 211212. 308.3 Acute Stress Disorder
Frances A, First MB, Pincus HA. DSM-IV Guidebook. American Psychiatric Press,
Inc.1995. Chapter 13: Anxiety Disorders. pages 237-273. (pages 263-266).
McGarvey EL, Canterbury RJ, Cohen RB. Evidence of acute stress disorder after
diagnosis of cancer. Southern Medical Journal. 1998; 91: 864-866.
18.08 Schizophrenia
18.08.01 The Chestnut Lodge Prognostic Scale for Patients with Chronic
Schizophrenia
Overview:
The Chestnut Lodge Prognostic Scale for Chronic Schizophrenia is a simple test for
assessing patients with schizophrenia which is independent of chronicity. It measures
prognosis as a dynamic interplay between skill acquisition and the relative virulence of
the illness.

Parameters
(1) adaptive occupational functioning
(2) social functioning
(3) psychotic assaultiveness (erosion of reality testing)
(4) depressed mood (preservation of affect)
(5) family history (genetic loading)
Aspect
acquisition
of skills and
interests

loner

psychotic
assaultiveness
depressed
mood

family
history of
schizophrenia

Parameter
Status
Rate on the basis of the highest level ever achieved works or
at any time before index admission. Base on
studies
information concerning occupational history
with
including work duties of student and housewife,
avocawith consideration for level of competence at these tional
jobs and extent to which patient experienced them interest
as personally meaningful (see status descriptions
below).
a set of
interests
few
interests
single
interest
no skills
On the basis of the highest level of social
Yes
competence since adolescence, has the patient ever
had a friend or group of friends?
No
(loner)
At any time before or during index admission, has
No
the patient been assaultive to others while
psychotic?
Yes
At any time since the onset of overt psychotic
Yes
illness, has the patient demonstrated signs of
depression as manifest by some or all of the
following: dysphoric mood, appetite and weight
loss, neurovegetative changes, feelings of
worthlessness, recurrent thoughts of death?
No
Is there a family history of schizophrenia, or
No
either prolonged hospitalization or hospitalization
with no return to normal functioning?
Yes

Points
4

3
2
1
0
2

0
2

0
2

0
2

Acquisition of skills and interests (explanation from table above)


(4) The patient is working at an occupation - or preparing him/herself for an occupation in which he/she is interested and in which he/she sees a future. In addition, he/she is
follwoing some avocational interest or interests. (If he/she occupational interests seem
complete, but there is no avocational pursuits, rank at 3).
(3) The patient has worked somewhat steadily at something he/she enjoys, but in which
he/she sees no future, or although working at different jobs, has developed a set of
interests or hobbies whcih he/she is pursuing with some vigor and interest (perhaps a
sport, music, or collection).
(2) The patient has been able to earn money at jobs that require some low level skill (e.g.,
fry cook or construction worker). He/she has not seemed to settle on an occupation
that interests him/her and seems to have developed few interests or skills beyond
these self-sustaining efforts.
(1) The patient may have developed a hobby or talent to the point of being fairly
proficient. It does not have the potential for financial reward, and it does not seem to
bring the patient much closer to others. The overall impression is that the hobby or
interest is a lone exception in a life otherwise lacking in skills.
(0) The patient seems to have developed no skills that would help him/her sustain
him/herself, develop friendships, or gratify curiosities and interests. There is no
indication of either occupational endeavors or hobbies.
Chestnut Lodge prognostic scale =
= SUM(points for all 5 aspects)
Interpretation
minimum score: 0
maximum score: 12
The lower the score the more likely a poor outcome will occur.
Porr outcome can be predicted with greater sensitivity than good outcome.
Prognostic Scale

Poor Outcome

1-3
4-6
7-9
10 - 12

87%
79%
56%
15%

Moderate
Outcome
13%
19%
27%
30%

Good Outcome
0%
2%
16%
55%

Limitations
Advances in chemotherapeutic agents may alter the expected outcome for a given score.
References:
Fenton WS, McGlashan TH. Prognostic scale for chronic schizophrenia. Schizophrenia
Bulletin. 1987; 13: 277-286.

18.09 Tardive Dyskinesia


18.09.01 Dyskinesia Identification System: Condensed User Scale (DISCUS)
Overview:
The Dyskinesia Identification System: Condensed User Scale (DISCUS) was developed
as a standardized rating scale to to evaluate patients for signs of tardive dyskinesia. The
DISCUS total score may be followed over time to assess a patient's response to different
therapeutic interventions.
Patient Evaluation
A standardized evaluation form was developed for recording clinical findings (see Figure
1, page 53, Sprague 1991).
15 movements seen in tardive dyskinesia divided into 7 body areas as follows:
Body Area
facial
ocular
oral
lingual

head, neck, trunk


upper limb
lower limb

Movements
tics
grimaces
blinking
chewing or lip smacking
puckering, sucking, or thrusting lower lip
tongue thrusting, or tongue in cheek
tonic tongue
tongue tremor
athetoid, myokymic, lateral tongue
retrocollis or torticollis
shoulder or hip torsion
athetoid, myokymic finger-wrist-arm
pill rolling
ankle flexion or foot tapping
toe movement

Movement Assessment
Each movement is scored according to the following schema:
Level
not present

minimal

Description
movements not observed or some
movements observed but not considered
abnormal
abnormal movements are difficult to detect
or movements are easy to detect but occur
only once or twice in a short non-repetitive
manner

Score
0

mild
moderate
severe
not assessed

abnormal movements occur infrequently


and are easy to detect
abnormal movements occur frequently and
are easy to detect
abnormal movements occur almost
continuously and are easy to detect
an assessment for an item is not able to be
made

2
3
4
NA

total score =
= SUM(points for all 15 items)
Interpretation
The DISCUS total score >= 5 is a valid measure of tardive dyskinesia.
References:
Sprague RL, Kalachnik JE. Reliability, validity, and a total score cutoff for the Dyskinesia
Identification System: Condensed User Scale (DISCUS) with mentally ill and
mentally retarded populations. Psychopharmacology Bulletin. 1991; 27: 51-58.
18.09.02 Abnormal Involuntary Movement Scale (AIMS)
Overview:
The Abnormal Involuntary Movement Scale (AIMS) is a method for evaluating a patient
for dyskinesias related to antipsychotic medication. This can be used to monitor a patient
over time. It was developed by the US Department of Health, Education and Welfare.
Examination procedure:
(1) Ask the patient whether there is anything in his/her mouth and, if there is, to remove
it.
(2) Ask the patient about the current condition of his/her teeth. Ask the patient if he/she
wears dentures. Do the teeth or dentures bother the patient now?
(3) Ask the patient whether he/she notices any movements in the mouth, face, hands or
feet. If "yes", ask to describe and to what extent they currently bother the patient or
interfere with his/her activities.
(4) Have the patient sit in a firm, armless chair with hands on knees, legs slightly apart,
and feet flat on the floor. Look at the entire body for movements while in this
position.
(5) Ask the patient with hands hanging unsupported. If male, between legs. If female and
wearing a dress, hanging over knees. Observe the hands and other body areas.
(6) Ask the patient to open his/her mouth. Observe the tongue at rest within the mouth.
Do this twice.
(7) Ask the patient to protrude the tongue. Observe abnormalities of tongue movement.
Do this twice.

(8) Ask the patient to tap thumb, with each finger, as rapidly as possible for 10-15
seconds; separately with right hand, then with left hand. Observe facial and leg
movements.
(9) Flex and extend the patient's left and right arms, one at a time. Note any rigidity.
(10) Ask the patient to stand up. Observe in profile. Observe all body areas again,
including hips.
(11) Ask the patient to extend both arms outstreched in front with palms down. Observe
the trunk, legs and mouth.
(12) Have the patient walk a few paces, trun, and walk back to the chair. Observe the
hands and gait. Do this twice.
In addition, the patient should be observed unobtrusively either before or after the
examination procedure.
Group
facial and oral
movements

extremity
movements

trunk movements
global assessments

dental status

Observation
Comments
muscles of facial expression movements of forehead, eyebrows,
periorbital area, cheeks; frowning,
blinking, smiling, grimacing
lips and perioral area
puckering, pouting, smacking
jaw
biting, clenching, chewing, mouth
opening, lateral movements
tongue
rate only increase in movements in
and out of mouth
arms, wrists, hands, fingers choreic movements, athetoid
movements; does not include
tremor
legs. knees, ankles, toes
lateral knee movement, foot
tapping, heel dropping, foot
squirming, inversion and eversion
of foot
neck, shoulders, hips
rocking, twisting, squirming, pelvic
gyrations
severity of abnormal
movements
incapacitation from
abnormal movements
patient awareness
current problems with
teeth and/or dentures
dentures worn

Rate the highest severity of a movement observed.


Rating for Movements

Points if
Spontaneous

Points if with
Activation

none
minimal
mild
moderate
severe

Rating for Patient


Awareness
no awareness
aware, no distress
aware, mild distress
aware, moderate distress
aware severe distress

Rating for Dental Status


no
yes

0
1
2
3
4

0
0
1
2
3

Points
0
1
2
3
4

Points
0
1

abnormal involuntary movement scale (AIMS) =


= SUM(points for all observations)
Interpretation:
minimum score: 0
maximum score: 42 (40 for abnormal movements)
The higher the score, the more abnormal the involuntary movements.
References:
Beers MH, Berkow R, et al (editors). The Merck Manual of Diagnosis and Therapy,
Seventeenth Edition. Merck Research Laboratories. 1999. pages 1568-1569.
Campbell M, Palij M. Measurement of side effects including tardive dyskinesia.
Psychopharm Bulletin. 1985; 21: 1063-1082 (page 1077-1078).
Guy W. ECDEU Assessment Manual for Psychopharmacology. 1976.
18.10 Neuroleptic Malignant Syndrome
Overview:
The Neuroleptic Malignant Syndrome is difficult (1) to define precisely, (2) to separate
from other related syndromes and (3) to even specify precipitating agents. It appears to
be related to changes in central dopaminergic activity. One suggestion has been to rename
it the drug-induced central hyperthermic syndrome (Heyland, Can Med Assoc J. 1991;
145: 817-819). This is an area likely to be modified over the coming years.

18.10.01 Diagnostic Criteria of Caroff et al for the Neuroleptic Malignant


Syndrome
Overview:
The Neuroleptic Malignant Syndrome (NMS) is a syndrome which may occur in patients
receiving neuroleptic agents. Its presentation and symptoms may vary, but the classic
tetrad is fever, rigidity, altered sensorium and autonomic dysfunction. It can be fatal if
unrecognized. Caroff et al specified diagnostic criteria to aid in its recognition.
Diagnostic Criteria for NMS
(1) treatment with neuroleptic agent prior to onset
within 7 days for oral agents
within 2-4 weeks for depot forms
(2) hyperthermia >= 38C (may be delayed in onset)
(3) muscle rigidity
(4) 5 or more of the following
change in mental status
tachycardia
hypertension or hypotension
tachypnea or hypoxia
diaphoresis (excessive sweating) or sialorrhea (excessive flow of saliva)
tremor
incontinence
creatine phosphokinase (CK) elevation or myoglobinuria
leukocytosis
metabolic acidosis
(5) exclusion of other drug-induced, systemic or neuropsychiatric illnesses
Limitations
This definition requires use of a neuroleptic agent. Other authors include nonneuroleptic agents, but this introduces the problems of differentiation from the other
conditions with overlapping symptomatology.
References:
Caroff SN, Mann SC, et al. Neuroleptic malignant syndrome. Diagnostic issues.
Psychiatric Annals. 1991; 21: 130-147.
Chan TC, Evans SD, Clark RF. Drug-induced hyperthermia. Critical Care Clinics. 1997;
13: 785-808.
Lev R, Clark RF. Neuroleptic malignant syndrome presenting without fever: Case report
and review of the literature. J Emerg Med. 1994; 12: 49-55.
18.11 The Serotonin Syndrome
18.11.01 Criteria for the Diagnosis of the Serotonin Syndrome
Overview:

The serotonin syndrome, also referred to as the toxic serotonin syndrome (TSS) is a
symptom complex caused by an increase in the biologic activity of serotonin. It most
often occurs in patients being treated concurrently with 2 or more drugs that increase
brainstem serotonin activity or stimulate serotonin receptors. It is associated with several
of the medications used to treat depression or other psychiatric conditions, and it has
been noticed more often since the introduction of the selective serotonin reuptake
inhibitors (SSRI).
Criteria for the diagnosis of the serotonin syndrome
(1) 3 or more of the following are present
confusion, hypomania or other mental status change
agitation, restlessness (akathisia)
frightened, diaphoretic hyperarousal state
myoclonus
hyperreflexia
diaphoresis
shivering, may be uncontrollable
tremor
diarrhea
incoordination
oculogyric crisis
fever
(2) onset of symptoms coincident with the addition or increase in a drug with serotonergic
activity
(3) a neuroleptic (antipsychotic agent) was not started or increased in dosage prior to the
onset of symptoms
(4) other etiologies (infectious, metabolic, drug abuse, withdrawal syndrome, poisoning)
have been excluded
Agents potentially causing the serotonin syndrome (after Table 2, Mills, 1995)
(1) increase in serotonin synthesis
L-tryptophan
(2) decrease serotonin metabolism
mono-amine oxidase (MAO) inhibitors (isocarboxazid, phenelzine, selegiline,
tranylcypromine)
(3) increase serotonin release
amphetamines
cocaine
fenfluramine
reserpine (initially)
(4) inhibition of serotonin uptake
tricyclic antidepressants (TCA): amitriptyline, clomipramine, desipramine, doxepin,
imipramine, nortriptyline, protriptyline
selective serotonin reuptake inhibitors (SSRI): fluvoxamine, fluoxetine, paroxetine,
nefazodone, sertaline, trazodone
amphetamines

cocaine
dextromethorphan
meperidine
venlafaxine
(5) direct serotonin receptor agonists
buspirone
LSD
sumatriptan
(6) nonspecific increase in serotonin activity
lithium
electroconvulsive therapy
(7) dopamine agonists
amantadine
bromocriptine
bupropion
levodopa
Management
(1) discontinue medication(s) with serotonergic activity
(2) supportive care
(3) consider administration of a nonselective serotonin receptor antagonist (methysergide,
cyproheptadine or propranolol)
References:
Dursun SM, Mathew VM, Reveley MA. Toxic serotonin syndrome after fluoxetine plus
carbamazepine. Lancet. 1993; 342: 442-443.
Dursun SM, Burke JG, Reveley MA. Toxic serotonin syndrome or extrapyramidal side
effects (Correspondence). Br J Psychiatry. 1995; 166: 401-402.
LoCurto MJ. The serotonin syndrome. Emergency Medicine Clinics of North America.
1997; 15: 665-675.
Martin TG. Serotonin Syndrome. Annals of Emergency Medicine. 1996; 28: 520-526.
Mills KC. Serotonin Syndrome. American Family Physician. 1995; 52: 1475-1482.
Mills KC. Serotonin Syndrome. Critical Care Clinics. 1997; 13: 763-783.
Sternbach H. The serotonin syndrome. Am J Psychiatry. 1991; 148: 705-713.
18.11.02 The Serotonin Syndrome Scale
Overview:
The Serotonin Syndrome Scale can be used to evaluate patients suspected of having the
Serotonin Syndrome. It provides a score based on 9 parameters based on the criteria
proposed by Sternbach.
Parameters evaluated
(1) agitation
(2) disorientation
(3) myoclonus

(4) hyperreflexia
(5) tremor
(6) dizziness
(7) hyperthermia
(8) sweating
(9) diarrhea
Parameter
agitation

disorders of
orientation

myoclonus

hyperreflexia

tremor

dizziness (subjective
feeling)

Finding
none
slight and intermittent
moderate (unrest sitting)
severe and permanent; prolonged sitting is
nearly impossible; patient always feels
restless
none
mild
moderate
severe, or more than 1 quality significantly
impaired
none
patient reports some short episodes
patient reports repeated episodes; isolated
myocloni are visible
permanent, visible myocloni
none
hyperreflexia with normal reflexogenic zone
hyperreflexia with enlarged reflexogenic zone;
exhaustible cloni
hyperreflexia with enlarged reflexogenic zone;
non-exhaustible cloni
none
tremor with small amplitude; functioning is
not impaired
tremor with a significant amplitude;
functioning (holding a cup, writing, etc.) is
moderately impaired
tremor with high amplitude; functioning
severely impaired
none
slight and intermittent feeling of dizziness
patient feels dizzy most of the time, but
functioning (moving, standing) is not impaired

Points
0
1
2
3

0
1
2
3
0
1
2
3
0
1
2
3
0
1
2

3
0
1
2

hyperthermia

sweating

diarrhea

patient always feels dizzy; functioning is


affected
sublingual temperature < 37C
sublingual temperature 37-37.9C
sublingual temperature 38-38.9C
sublingual temperature >= 39.0 37C
none
subjective feeling of increased sweating
moist skin, some beads of perspiration can be
seen
visible beads of perspiration with wet clothes
or bedspread
none
feces with reduced consistency, but normal
frequency
liquid feces and/or frequency 1-3 per day
liquid with frequency > 3 per day

3
0
1
2
3
0
1
2
3
0
1
2
3

where
agitation = motor restlessness, also akathisia
orientation = according to time, place, person or situation, with most severe expression
scored
myoclonus = sudden clinic jerks of some muscles without or with only little movement
effect; Sleeping jerks" should not be scored
sweating is evaluated at rest with normal environmental temperatures
serotonin syndrome score =
= SUM(points for all 9 items)
Interpretation
minimum score = 0
maximum score = 27
The serotonin syndrome is presumed present if the score is > 6 (corresponding to
moderate intensity of 3 or more symptoms)
References:
Hegerl U, Bottlender R, et al. The serotonin syndrome scale: first results on validity. Eur
Arch Psychiatry Clin Neurosci. 1998; 248: 96-103.
Sternbach H. The serotonin syndrome. Am J Psychiatry. 1991; 148: 705-713.
18.12 Attention Deficit Hyperactivity Disorder (ADHD)
18.12.01 Parents' Rating Scale for the Attention Deficit Hyperactivity Disorder
Overview:

The Parents's Rating Scale is completed by a parent of a person to be assessed for the
Attention Deficity Hyperactivity DIsorder.
Form Completion
The form is to be filled out by the mother if available. If not, the father should complete
the form.
Instructions
Listed below are items concerning children's behavior and the problems they sometimes
have.
Read each item carefully and decide how much you think you were bothered by these
problems when your child was between six and ten years old.
Rate the amount of the problem by putting a check in the column that describes your
child at that time.

restless and overactive


excitable, impulsive
disturbs other children
fails to finish things started
(short attention span)
fidgets
inattentive, distractible
demands must be met
immediately; gets frustrated
cries
mood changes quickly
temper outburts (explosive
and unpredictable behavior)

not at all
0
0
0
0

just a little pretty much


1
3
1
3
1
3
1
3

very much
4
4
4
4

0
0
0

1
1
1

3
3
3

4
4
4

0
0
0

1
1
1

3
3
3

4
4
4

parents' rating scale score =


= SUM(points for all 10 questions)
Interpretation
minimum score 0
maximum score 40
scores >= 12 places someone above the 95th percentile for childhood "hyperactivity"
References:
Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: An aid in the
retrospective diangosis of childhood Attention Deficity Hyperactivity Disorder. Am
J Psychiatry. 1993; 150: 885-890.
18.12.02 Wender Utah Rating Scale for the Attention Deficit Hyperactivity
Disorder

Overview:
The Wender Utah Rating Scale can be used to assess adults for Attention Deficit
Hyperactivity Disorder, with a subset of 25 questions associated with that diagnosis.
Wender Utah Rating Scale
61 questions answered by the adult patient recalling his or her childhood behavior
5 possible responses, scored from 0 to 4 points
As a child, I was (or had):

1
2
3
4
5
6
7
8
9
10

11
12
13
14
15
16
17
18
19
20
21
22

active, restless, always on the


go
afraid of things
concentration problems, easily
distracted
anxious, worrying
nervous, fidgety
inattentive, daydreaming
hot- or short-tempered, low
boiling point
shy, sensitive
temper outbursts, tantrums
trouble with stick-to-ittiveness, not following through.
failing to finish things started
stubborn, strong-willed
sad or blue, depressed,
unhappy
incautious. dare-devilish,
involved in pranks
not getting akick out of things,
dissatisfied with life
disobedient with parents,
rebellious, sassy
low opinion of myself
irritable
outgoing, friendly, enjoyed
company of people
sloppy, disorganized
moody, ups and downs
angry
friends, popular

not at all
or very
slightly
0

mildly moder- quite a


ately
bit

very
much

0
0

1
1

2
2

3
3

4
4

0
0
0
0

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

0
0
0

1
1
1

2
2
2

3
3
3

4
4
4

0
0

1
1

2
2

3
3

4
4

0
0
0

1
1
1

2
2
2

3
3
3

4
4
4

0
0
0
0

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

23
24
25
26
27
28
29

30
31
32
33
34
35
36
37
38
39
40
41

42

well-organized, tidy, neat


acting without thinking,
impulsive
tendency to be immature
guilty feelings, regretful
losing control of myself
tendency to be or act irrational
unpopular with other children,
didn't keep friends for long,
didn't get along with other
children
poorly coordinated, did not
participate in sports
afraid of losing control of self
well-coordinated, picked first in
games
tomboyish (for women only)
running away from home
getting into fights
teasing other children
leader, bossy
difficulty getting awake
follower, led around too much
trouble seeing things from
someone else's point of view
trouble with authorities, trouble
with school, visits to principal's
office
trouble with police, booked,
convicted

Medical problems as a child

43
44
45
46
47
48
49

headaches
stomachaches
constipation
diarrhea
food allergies
other allergies
bedwetting

0
0

1
1

2
2

3
3

4
4

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

0
0

1
1

2
2

3
3

4
4

0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4

not at all
or very
slightly
0
0
0
0
0
0
0

mildly moder- quite a


ately
bit
1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

very
much
4
4
4
4
4
4
4

As a child in school, I was (or


had)
50
51
52
53
54
55
56
57
58
59
60
61

overall a good student, fast


overall, a poor student, slow
learner
slow in learning to read
slow reader
trouble reversing letters
problems with spelling
trouble with mathematics or
numbers
bad handwriting
able to read pretty well but
never really enjoyed reading
not achieving up to potential
repeating grades
suspended or expelled

not at all
or very
slightly
0
0

mildly moder- quite a


ately
bit
1
1

2
2

3
3

4
4

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

4
4
4
4
4

0
0

1
1

2
2

3
3

4
4

0
0
0

1
1
1

2
2
2

3
3
3

4
4
4

Questions associated with ADHD


25 of the questions were associated with ADHD, as follows:

3
4
5
6
7
9
10
11
12
15
16
17
20
21
24
25
26
27

very
much

As a child, I was (or had):


concentration problems, easily distracted
anxious, worrying
nervous, fidgety
inattentive, daydreaming
hot- or short-tempered, low boiling point
temper outbursts, tantrums
trouble with stick-to-it-tiveness, not following through. failing to finish
things started
stubborn, strong-willed
sad or blue, depressed, unhappy
disobedient with parents, rebellious, sassy
low opinion of myself
irritable
moody, ups and downs
angry
acting without thinking, impulsive
tendency to be immature
guilty feelings, regretful
losing control of myself

28
29
40
41

tendency to be or act irrational


unpopular with other children, didn't keep friends for long, didn't get
along with other children
trouble seeing things from someone else's point of view
trouble with authorities, trouble with school, visits to principal's office

51
56
59

As a child in school, I was (or had)


overall, a poor student, slow learner
trouble with mathematics or numbers
not achieving up to potential

Wender Utah rating scale subscore =


= SUM(points for 25 questions associated with ADHD)
Interpretation
minimum score for the 25 questions is 0
maximum score 100
if a cutoff score of 46 was used, 86% of patients with ADHD, 99% of normal persons,
and 81% of depressed subjects were correctly classified
References:
Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: An aid in the
retrospective diangosis of childhood Attention Deficity Hyperactivity Disorder. Am
J Psychiatry. 1993; 150: 885-890.
18.12.03 Attention Deficit Hyperactivity Disorder ADD/H Adolescent Self-Report
Scale Short Form
Overview:
The ADD/H Adolescent Self-Report Scale short form is an instrument to screen for
symptoms of the attention deficit-hyperactivity disorder (ADHD). The scale is an
adaptation by AL Robin of the questionnaire developed by CK Conners and KC Wells.
Instructions:
Listed below are items concerning your behavior or problems you may sometimes have.
Read each item carefully and decide how much you think you have been bothered by this
problem during the past month. Indicate your choice by circling the number in the
appropriate column to the right of each item.
Statement
I have trouble concentrating on one thing at a
time.

Response
not at all
just a little
pretty much

Points
0
1
2

My mind wanders.

I have trouble keeping my thoughts organized.

I can't stick with things for more than a few


minutes.

I lose track of what I am supposed to be doing.

I get distracted easily.

It takes a lot of effort to get my schoolwork


done.

I tend to learn more slowly than I would like.

I have trouble organizing my schoolwork.

I don't make much effort at my schoolwork.

I am behind on my studies.

very much
not at all
just a little
pretty much
very much
not at all
just a little
pretty much
very much
not at all

3
0
1
2
3
0
1
2
3
0

just a little
pretty much
very much
not at all
just a little
pretty much
very much
not at all
just a little
pretty much
very much
not at all

1
2
3
0
1
2
3
0
1
2
3
0

just a little
pretty much
very much
not at all
just a little
pretty much
very much
not at all
just a little
pretty much
very much
not at all
just a little
pretty much
very much
not at all
just a little
pretty much
very much

1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3

total score =
= SUM(points for all 11 statements)
Interpretation:
minimum score: 0
maximum score: 33
A cutting score of 10 (I assume classifies 95% of ADHD patients and 90% of the nonADHD controls. The mean score for control was 5.3 with standard deviation of 3.7;
the mean score for ADHD adolescents was 17.8 with SD of 8.1.
References:
Conners CK, Wells KC. ADD-H adolescent self-report scale. Psychopharmacol Bull.
1985; 21: 991-992.
Robin AL, Vandermay SJ. Validation of a measure for adolescent self-report of Attention
Deficit Disorder symptoms. Develop Behavioral Pediatrics. 1996; 17: 211-215.
18.13 Screening Children for Psychosocial Dysfunction
18.13.01 Pediatric Symptom Checklist for Screening School-Age Children for
Psychosocial Dysfunction
Overview:
The Pediatric Symptom Checklist (PSC) is a questionnaire completed by parents of
children 6 to 12 years of age and is used to screen children for difficulty in pyschosocial
functioning.
Patient selection
children aged 6-12 years of age
Questions: Please mark under the heading that best fits your child:
(1) complains of aches or pains
(2) spends more time alone
(3) tires easily, little energy
(4) fidgety, unable to sit still
(5) has trouble with a teacher
(6) less interested in school
(7) acts as if driven by a motor
(8) daydreams too much
(9) distracted easily
(10) is afraid of new situations
(11) feels sad, unhappy
(12) is irritable, angry
(13) feels hopeless
(14) has trouble concentrating
(15) less interest in friends

(16) fights with other children


(17) absent from school
(18) school grade dropping
(19) is down on himself or herself
(20) visits physician, but physician finds nothing wrong
(21) has trouble with sleeping
(22) worries a lot
(23) wants to be with you more than before
(24) feels he or she is bad
(25) takes unnecessary risks
(26) gets hurt frequently
(27) seems to be having less fun
(28) acts younger than children his or her age
(29) does not listen to rules
(30) does not show feelings
(31) does not understand other people's feelings
(32) teases others
(33) blames others for his or her troubles
(34) takes things that do not belong to him or her
(35) refuses to share
Responses
never
sometimes
often

Score
0
1
2

pediatric symptom checklist score =


= SUM(scores for all 35 questions)
Interpretation
minimum score: 0
maximum score: 70
A positive PSC screening score is >= 28.
Performance evaluation showed a sensitivity of 95% and a specificity of 68%.
References
Anderson DL, Spratt EG, et al. Use fo the Pediatic Symptom Checklist in the pediatric
neurology population. Pediatric Neurology. 1999; 20: 116-120.
Jellinek MS, Murphy JM, et al. Pediatric symptom checklist: Screening school-age
children for psychosocial dysfunction. J Pediatrics. 1988; 112: 201-209.
Jellinek MS, Murphy JM. Screening for psychosocial disorders in pediatric practice. Am
J Dis Child. 1988; 142: 1153-1157.
18.14 Shared Delusional States

18.14.01 Mass Psychogenic Illness (Environmental Somatization Syndrome)


Overview:
Mass psychogenic illness, also known as environmental somatization syndrome, group
conversion rection, collective delusion or epidemic hysteria, may occur when a group of
people believe that they have undergone a harmful environmental exposure to something
(contagious agent, chemical, electricity, magnetic, physical, etc.) yet there is no objective
evidence for this despite a careful evaluation. This often involves group somatization,
with psychogenic distress manifested in the form of physical symptoms.
Features:
(1) relatively severe symptoms of sudden onset in a number of people, particularly after
leaving the purported source of the exposure
(2) transmission of illness by sight or sound
(3) symptoms occur after learning of suspected exposure or seeing someone else with
illness
(4) rapid spread with rapid remission
(5) diversity of symptoms without physicals signs or laboratory findings (absence of
objective medical findings)
(6) relapse of symptoms when affected persons congregate
(7) absence of significant environmental findings
(8) absence of the usual symptoms expected from exposure to the alleged contaminant or
source material
(9) higher attack rate among females than males when the population at risk includes both
sexes
(10) benign morbidity with lack of sequelae
(11) occasionally may show conversion symptoms (loss or alteration of physical
functioning, not under voluntary control) that cannot be explained by any physical
disorder or known pathophysiologic mechanism
(12) affected persons may strongly defend their beliefs and refuse any alternative
explanation for their symptoms
Frequent complaints
headache
faintness
dizziness
nausea
chest tightness
difficulty breathing
irritation of eyes, nose or throat
weakness
numbness
palpitations
vague pains in different parts of the body
difficulty with concentration and/or memory

Differential diagnosis
(1) sick building syndrome
(2) true chemical or biological exposure
Management
(1) remove affected persons from stimulating environment
(2) separate the group as quickly as possible and try to keep it from regathering
(3) do not downplay or minimize the patient's concerns
(4) try to identify anyone with a true toxic, allergic or infectious disease
(5) emphasize the certainties of the situation and provide information as needed
(6) a mild tranquilizer may be considered during the acute episode
(7) give explicit followup instructions, with actions to take if the symptoms recur
(8) if the diagnosis is in doubt, perform a careful environmental survey
(9) if the diagnosis is likely, try to address the anxiety and depression
References:
Boxer PA. Occupational mass psychogenic illness. J Occupational Med. 1985; 27: 867872.
Gothe CJ, Molin C, Nilsson CG. The environmental somatization syndrome.
Psychosomatics. 1995; 36: 1-11.
Kirk M, Pace S. Pearls, pitfalls, and updates in toxicology. Emerg Med Clin N Am. 1997;
15: 427-449.
18.14.02 Delusions Shared By Two or More People (Folie a Deux, etc.)
Overview:
A delusion may be shared by a small group of persons. This is referred to as "folie"
(French for madness or lunacy).
Characteristics:
(1) The presence of a situation generating strong emotions (death, loss, strife, etc.).
(2) The primary delusion is developed by a strong-willed individual of a group.
(3) Other members of the group share the same delusion (folie partage) because of:
domination by the strong-willed person
excessive devotion or misplaced loyalty
excessive desire to maintain harmony in the group
(4) The delusion may last from a few weeks to many years.
(5) The delusion is maintained despite the absence of objective data.
The shared delusion may involve a variety of conditions, such as parasitic infestation
(delusional parasitosis). The group may visit many physicians or other health care
providers.
Number of People
Involved
2

Term
folie a deux

3
4
5
6

folie a trois
folie a quatre
folie a cinq
folie a six

References:
Freinhar JP. Delusions of parasitosis. Psychosomatics. 1984; 25: 47-53.
Gieler U, Knoll M. Delusional parasitosis as 'Folie a' trois'. Dermatologica. 1990; 181:
122-125.
Lynch PJ. Delusions of parasitosis. Seminars Dermatology. 1993; 12: 39-45.
Schwartz E, Witztum E, Mumcuoglu KY. Travel as a trigger for shared delusional
parasitosis. J Travel Med. 2001; 8: 26-28.
Wykoff RF. Delusions of parasitosis: A review. Rev Infect Dis. 1987; 9: 433-437.
18.15 Eating Disorders
18.15.01 Criteria for Bulimia Nervosa
Overview:
Bulimia nervosa is characterized by episodes of compulsive, secretive binge eating
followed by compensatory acts to prevent weight gain.
Criteria:
(1) Recurrent episodes of binge eating.
(2) Recurrent inappropriate compensatory behavior to prevent weight gain, which may be
further classified as purging or nonpurging (see below).
(3) Binge eating and inappropriate compensatory behaviors both occur, on average, at
least twice a week for 3 months.
(4) Self-evaluation is unduly influenced by body shape and weight.
(5) The disturbance does not occur exclusively during episodes of anorexia nervosa.
Binge eating may involve one or both of the following:
(1) eating in a discrete period of time (a few hours) an amount of food that is definitely
larger than most people would eat during a similar period of time and under similar
circumstances
(2) a sense of lack of control over eating during the episode. This may involve a feeling of
an inability to stop eating or to control how much is being consumed.
Subtypes
(1) purging type: regularly engages in self-induced vomiting or the misuse of laxatives,
diuretics or enemas
(2) nonpurging type: regularly engages in inappropriate compensatory behaviors, such as
fasting or excessive exercise
Complications

menstrual irregularities
gastrointestinal abnormalities, especially in the esophagus
aspiration pneumonia
adverse effects related to diuretic or purgative agent
References:
American Psychiatric Association. Diagnostic Criteria from DSM-IV. 1994. 307.51,
pages 252-253.
Frances A, First MB, Pincus HA. DSM-IV Guidebook. American Psychiatric Press, Inc.
1995. pages 327-329.
Horowitz M, Camilleri. Chapter 15: Gastric and intestinal motility disorders. pages 423450 (436-437). IN: Shearman DJC, Finlayson N, et al (editors). Diseases of the
Gastrointestinal Tract and Liver, Third Edition. Churchill Livingstone. 1997.
18.15.02 Criteria for Anorexia Nervosa
Overview:
Anorexia nervosa is an eating disorder occurring mostly in young women which features
low body weight for height associated with an abnormal fear of being overweight or fat.
Patient characteristics in the US
Most patients are Caucasian females, although males may be affected.
For women, the onset is usually within 8 years of menarche.
Patients are often from an affluent family.
Energy and activity are often unimpaired.
The person usually maintains his or her appetite.
Criteria
(1) Refusal to maintain body weight at or above a minimally normal weight for age and
height.
(2) An intense fear of gaining weight or becoming fat, even though below ideal body
weight
(3) A distorted body image with a disturbance in the perception of own body weight or
shape, an undue influence placed on body weight or shape in self-evaluation, and/or
denial of the seriousness of current low body weight
(4) In post-menarcheal females, the presence of amenorrhea, with absence of at least 3
consecutive menstrual cycles
where:
There is no specific cut-off for "minimally normal" body weight.
Guidelines are (1) < 85% of ideal body weight for height and weight, (2) a body mass
index < 17.5 kg per meter squared.
The amenorrhea usually is related to low serum estrogen levels, and periods may occur
after hormone (estrogen) replacement.
Subtypes

(1) restricting: the patient does not regularly engage in binge-eating followed by purging
behavior, with weight loss maintained by dietary restriction and exercise
(2) binge-eating and purging: during episodes of anorexia, the patient regularly is engaged
in binge-eating followed by purging behavior, similar to that seen in bulimia nervosa
Complications
emaciation
hypotension
bradycardia, cardiac arrhythmias
hypothermia
acrocyanosis
carotenemia
dry skin
diffuse growth of lanugo hair
ankle edema
dehydration or hypokalemia with vomiting, or laxative/diuretic abuse
Differential diagnosis
(1) underlying disease causing weight loss (malignancy, gastrointestinal tract dosease,
metabolic disorder)
(2) slender person below mean for height and weight
(3) person maintaining slender physique to participate in profession (gymnastics, dance,
modeling, etc.)
References:
American Psychiatric Association. Diagnostic Criteria from DSM-IV. 1994. 307.1, pages
251-252.
Frances A, First MB, Pincus HA. DSM-IV Guidebook. American Psychiatric Press, Inc.
1995. pages 326-327.
Horowitz M, Camilleri. Chapter 15: Gastric and intestinal motility disorders. pages 423450 (437-438). IN: Shearman DJC, Finlayson N, et al (editors). Diseases of the
Gastrointestinal Tract and Liver, Third Edition. Churchill Livingstone. 1997.
18.15.03 Criteria for Eating Disorder Not Otherwise Specified
Overview:
An Eating Disorder Not Otherwise Specified may be diagnosed if (1) a person has an
eating disorder that (2) does not quite meet the critiera for anorexia nervosa or bulimia
nervosa.
Features
(1) anorexia nervosa like, except
has regular menses
body weight above cut-off used
(2) bulimia nervosa like, except
frequency of binging-purging is less than 2 times per week

duration of binging-purging is less than 3 months


purges after minor food intake
chews a large amount of food, but spits it out without swallowing
References:
American Psychiatric Association. Diagnostic Criteria from DSM-IV. 1994. 307.1, pages
253-254
Frances A, First MB, Pincus HA. DSM-IV Guidebook. American Psychiatric Press, Inc.
1995. pages 330
18.15.04 The SCOFF Questionnaire Screening Insturment for Eating Disorders
Overview:
The SCOFF questionnaire is a simple interview instrument which can be used to screen
people for eating disorders such as anorexia nervosa or bulimia.
Questions:
(S) Do you make yourself Sick because you feel uncomfortably full?
(C) Do you worry you have lost Control over how much you eat?
(O) Have you recently lost One stone (about 14 pounds) in a 3 month period?
(F) Do you believe yourself Fat when others say you are too thin?
(F) Would you say that Food dominates your life?
Scoring:
One point is assigned for each "Yes" answer.
SCOFF score =
= SUM(points for the 5 questions)
Interpretation:
minimum score: 0
maximum score: 5
A score >= 2 indicates that the person may have anorexia nervosa or bulimia and further
evaluation is warranted.
References:
Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: Assessment of a new screening
tool for eating disorders. BMJ. 1999; 319: 1467-1468.
18.15.05 The Eating Attitudes Test for Symptoms of Anorexia Nervosa
Overview:
The Eating Attitude Test (EAT) is a questionnaire for detecting symptoms associated
with anorexia nervosa. It uses a 6 point, forced choice, Likert scale for responses. 7 item
groups were identified: (1) food pre-occupation, (2) body image for thinness, (3) vomiting

and laxative abuse, (4) dieting, (5) slow eating, (6) clandestine eating, and (7) perceived
social pressure to gain weight.
Instructions:
Please place an (X) under the column which applies best to each of the numbered
statements. All of the results will be strictly confidential. Most of the questions directly
relate to food or eating, although other types of questions have been included. Please
answer each question carefully. Thank you.
Statements:
(1) I like eating with other people
(2) I prepare foods for others but do not eat what I cook
(3) I become anxious prior to eating
(4) I am terrified about being overweight
(5) I avoid eating when I am hungry
(6) I find myself preoccupied with food
(7) I have gone on eating binges where I feel that I may not be able to stop
(8) I cut my food into small pieces
(9) I am aware of the coloric content of foods that I eat
(10)I particularly avoid foods with a high carbohydrate content (bread, potatoes, rice,
etc.)
(11) I feel bloated after meals
(12) I feel that others would prefer if I ate more
(13) I vomit after I have eaten
(14) I feel extremely guilty after eating
(15) I am preoccupied with a desire to be thinner
(16) I exercise strenuously to burn off calories
(17) I weigh myself several times a day
(18) I like my clothers to fit tightly
(19) I enjoy eating meat
(20) I wake up early in the morning
(21) I eat the same foods day after day
(22) I think about burning up calories when I exercise
(23) I have regular menstrual periods (if female)
(24) Other people think that I am too thin
(25) I am preoccupied with the thought of having fat on my body
(26) I take longer than others to eat my meals
(27) I enjoy eating at restaurants
(28) I take laxatives
(29) I avoid foods with suger in them
(30)I eat diet foods
(31) I feel that food controls my life
(32) I display self control around food
(33) I feel that others pressure me to eat
(34) I give too much time and thought to food
(35) I suffer from constipation

(36) I feel uncomfortable after eating sweets


(37) I engage in dieting behavior
(38) I like my stomach to be empty
(39) I enjoy trying new rich foods
(40) I have the impulse to vomit after meals
Responses
always
very often
often
sometimes
rarely
never

"Forward"
0
0
0
1
2
3

"Reverse"
3
2
1
0
0
0

Scoring
forward: 1, 19, 23, 39
reverse: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 24, 25, 26, 27,
28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40
Interpretation:
minimal score: 0
maximal score: 120 for women, 117 for men
A score > 30 is found in patients with anorexia nervosa. About 7% of non-anorexic,
"normal" persons will have a score >30; all of these had a score <= 40).
Recovered anorexic patients score in the normal range indicating that the test may be
sensitive to clinical remission.
Performance characteristics:
The alpha reliability coefficient 0.79 for anorexia nervosa patients and 0.94 for the
pooled sample of anorexia and normal control patients.
The validity coefficient was 0.87.
References:
Garner DM, Garfinkel PE. The Eating Attitudes Test: An index of the symptoms of
anorexia nervosa. Psycholog Med. 1979; 9: 273-279.
18.16 Psychological Measures of Alcohol Abuse
18.16.01 The Obsessive Compulsive Drinking Scale
Overview:
The Obsessive Compulsive Drinking Scale is a self-rating instrument that measures some
of the cognitive aspects of alcohol craving and which may be useful in assessing the
severity of alcoholism and treatment outcome.

Administration
The subject fills out the questionaire, indicating the answer to each question which bests
applies to him/herself. The test can be administered before, during and after treatment
intervention.
# Question
1 How much of your time when you're not drinking is occupied by
ideas, thoughts, impulses or images related to drinking?
none
less than 1 hour per day
1-3 hours a day
4-6 hours a day
greater than 8 hours a day
2 How frequently do these thoughts occur?
never
no more than 8 times a day
more than 8 times a day, but most hours of the day are free of
such thoughts
more than 8 times a day and during most hours of the day
thoughts are too numerous to count and an hour rarely passes
without several such thoughts occurring
3 How much do these ideas, thoughts, impulses or images related to
drinking interfere with your social or work (or role) functioning?
(If you are not currently working, how much of your performance
would be affected if you were working?)
thoughts of drinking never interfere - I can function normally
thoughts of drinking slightly interfere with my social or
occupational activities, but my overall performance is not impaired
thoughts of drinking definitely interfere with my social or
occupational performance but I can still manage
thoughts of drinking cause substantial impairment of my social or
occupational performance
thoughts of drinking interfere completely with my social or work
performance
4 How much distress or disturbances do these ideas, thoughts,
impulses, or images related to drinking cause you when you're not
drinking?
none
mild, infrequent and not too disturbing
moderate, frequent, and disturbing, but still manageable
severe, very frequent, and very disturbing
extreme, nearly constant, and disabling distress

Value

0
1
2
3
4
0
1
2
3
4

0
1
2
3
4

0
1
2
3
4

5 How much of an effort do you make to resist these thoughts or try


to disregard or turn your attention away from these thoughts as
they enter your mind when you're not drinking?
(Rate your efforts made to resist these thoughts, not your success
or failure in actually controlling them.)
My thoughts are so minimal, I don't need to actively resist. If I
have thoughts, I make an effort to always resist.
I try to resist most of the time.
I make some effort to resist.
I give in to all such thoughts without attempting to control them,
but I do so with some reluctance.
I completely and willingly give in to all such thoughts.
6 How successful are you in stopping or diverting these thoughts
when you're not drinking?
I am completely successful in stopping or diverting such
thoughts.
I am usually able to stop or divert such thoughts with some
effort and concentration.
I am sometimes able to stop and divert such thoughts.
I am rarely successful in stopping such thoughts and can only
divert such thoughts with difficulty.
I am rarely able to divert such thoughts even momentarily.
7 How many drinks do you drink each day?
none
less than one drink per day
1-2 drinks per day
3-7 drinks per day
8 or more drinks per day
8 How many days each week do you drink?
none
no more than 1 day per week
2-3 days per week
4-5 days per week
6-7 days per week
9 How much does your drinking interfere with your work
functioning? Is there anything that you don't or can't do because of
your drinking? (If you are not currently working, how much of
your performance would be affected if you were working?)
Drinking never interferes - I can function normally.
Drinking slightly interferes with my occupational activities, but
my overall performance is not impaired.
Drinking definitely interferes with my occupational performance
but I can still manage.

0
1
2
3
4

0
1
2
3
4
0
1
2
3
4
0
1
2
3
4

0
1
2

10

11

12

13

14

Drinking causes substantial impairment in my occupational


performance.
Drinking problem interfere completely with my work
performance.
How much does your drinking interfere with your social
functioning? Is there anything that you don't or can't do because of
your drinking?
Drinking never interferes - I can function normally.
Drinking slightly interferes with my social activities, but my
overall performance is not impaired.
Drinking definitely interferes with my social performance but I
can still manage.
Drinking causes substantial impairment in my social
performance.
Drinking problem interfere completely with my social
performance.
If you were prevented from drinking alcohol when you desired a
drink, how anxious or upset would you become?
I would not experience any anxiety or irritation.
I would become only slightly anxious or irritated.
The anxiety or irritation would mount but remain manageable.
I would experience a prominent and very disturbing increase in
anxiety or irritation.
I would experience incapacitating anxiety or irritation.
How much of an effort do you make to resist consumption of
alcoholic beverages? (Only rate your effort to resist, not your
success or failure in actually controlling the drinking.)
My drinking is so minimal, I don't need to actively resist. If I
drink, I make an effort to always resist.
I try to resist most of the time.
I make some effort to resist.
I give to almost all drinking without attempting to control it, but
I do so with some reluctance.
I completely and willingly give in to all drinking.
How strong is the drive to consume alcoholic beverages?
No drive.
Some pressure to drink.
Strong pressure to drink.
Very strong drive to drink.
The drive to drink is completely involuntary and overpowering.
How much control do you have over the drinking?
I have complete control.
I am usually able to exercise voluntary control over it.
I can control it only with difficulty.

3
4

0
1
2
3
4

0
1
2
3
4

0
1
2
3
4
0
1
2
3
4
0
1
2

I must drink and can only delay drinking with difficulty.


I am rarely able to delay drinking even momentarily.

3
4

obsessive compulsive drinking scale =


= MAX(value 1, value 2) + (value 3)+ (value 4)+ (value 5)+ (value 6)+ MAX(value 7,
value 8) + MAX(value 9, value 10) + (value 11)+ (value 12)+ MAX(value 13, value 14)
Interpretation
maximum score: 40
minimum score: 0
scores correlate with alcohol craving, alcohol dependence and alcohol consumption, with
higher scores indicating more severe affliction
scores after treatment correlate with abstinence, "slip" drinking and relapse drinking,
with abstainers showing lower scores and relapsers showing higher scores
References:
Anton RF, Moak DH, Latham P. The Obsessive Compulsive Drinking Scale: A self-rated
instrument for the quantification of thoughts about alcohol and drinking behavior.
Alcohol Clin Exp Res. 1995; 19: 92-99.
Anton RF, Moak DH, Latham PK. The obsessive compulsive drinking scale. Arch Gen
Psychiatry. 1996; 53: 225-231.
Modell JG, Glaser FB, et al. Obsessive and compulsive characteristics of alcohol abuse
and dependence: Quantification by a newly developed questionnaire. Alcohol Clin
Exp Res. 1992; 16: 266-271.
Modell JG, Glaser FB, et al. Obsessive and compulsive characteristics of craving for
alcohol in alcohol abuse and dependence. Alcohol Clin Exp Res. 1992; 16: 272-274.
18.16.02 The Brief Michigan Alcoholism Test
Overview:
The Brief Michigan Alcoholism Test allows rapid assessment of patients for alcohol
abuse.
Questions
Do you feel you are a normal drinker? (Y or N)
Do friends or relatives think you are a normal drinker? (Y
or N)
Have you ever attended a meeting of Alcoholics
Anonymous? (Y or N)
Have you ever lost friends, girlfriends, or boyfriends
because of drinking? (Y or N)

Response
yes
no
yes

Points
0
2
0

no
yes

2
5

no
yes

0
2

no

Have you ever gotten in trouble at work because of


drinking? (Y or N)
Have you ever neglected your obligations, your family, or
your work for 2 or more days in a row because you were
drinking? (Y or N)
Have you ever had delirium tremens (DTs), had severe
shaking, heard voices, or seen things that weren't there
after heavy drinking? (Y or N)
Have you ever gone to someone for help about your
drinking? (Y or N)
Have you ever been in a hospital because of drinking? (Y
or N)
Have you ever been arrested for drunk driving or driving
after drinking? (Y or N)

yes

no
yes

0
2

no
yes

0
2

no
yes

0
5

no
yes

0
5

no
yes

0
2

no

Interpretation
maximum score 29
minimum score 0
scores >= 6 indicate probable alcohol abuse
References:
Crowley TJ. Alcoholism: Identification, evaluation and early treatment. West J Med.
1984; 140: 461-464.
Selzer ML. The Michigan Alcoholism Screening Test: The quest for a new diagnostic
instrument. Amer J Psychiat. 1971; 127: 1653-1658.
Speicher CE. The Right Test, 2nd Edition. W.B. Saunders Company. 1993. pages 45-50.
18.16.03 The TWEAK Screening Test
Overview:
The TWEAK screening test is a rapidly administered instrument which can be used to
screen for heavy alcohol drinking. It has proven useful in assessing alcohol use by women
during pregnancy.
Parameter
(T) Tolerance
(T) Tolerance (variant
question)

Question
How many drinks can you hold without falling asleep or
passing out?
How many drinks do you need before you need to get
high?

(W) Worried
(E) Eye-opener
(A) Amnesia

(K) Cut Down

Have close friends or relatives worried about your


drinking in the past year?
Do you sometimes take a drink in the morning when
you first get up?
Has a friend or family member ever told you about
things you said or did while you were drinking that you
could not remember?
Do you sometimes feel the need to cut down on your
drinking?

Parameter
(T) Tolerance (pass out), woman
(T) Tolerance (pass out), man
(T) Tolerance (get high)
(W) Worried
(E) Eye-opener
(A) Amnesia
(K) Cut Down

Response
<5
>= 5
<8
>= 8
<3
>= 3
no
yes
no
yes
no
yes
no
yes

Points
0
2
0
2
0
2
0
2
0
1
0
1
0
1

where:
Chan et al looked at different cut off points for tolerance. The actual number used
depends on desire for sensitivity or specificity.
If a person never passes out while drinking, the largest number of drinks consumed
should be recorded.
TWEAK score =
= SUM(points for the 5 parameters)
Interpretation:
minimum score: 0
maximum score: 7
A score >=2 indicates that the person may be a drinker at risk.
References:

Allen JP, Columbus M (editors). Assessing Alcohol Problems. A Guide for Clinicians and
Researchers. National Institute on Alcohol Abuse and Alcoholism. NIH 95-3745.
1995. pages 540-545
Chan AWK, Pristach EA, et al. Use of the TWEAK test in screening for alcholism/heavy
drinking in three populations. Alcohol Clin Exp Res. 1993; 17: 1188-1192.
Russell M. New assessment tools for risk drinking during pregnancy. Alcohol Health &
Research World. 1994; 18: 55-61.
18.16.04 The Alcohol Use Disorders Identification Test (AUDIT) Core
Questionnaire
Overview:
The Alcohol Use Disorders Identification Test (AUDIT) core questionnaire can be used
to screen patients for harmful alcohol consumption. It was developed by the World
Health Organization and has been used around the world in many languages.
Compenents of 10-item questionnaire:
(1) 3 questions on amount and frequency of drinking
(2) 3 questions on alcohol dependence
(3) 4 questions on problems caused by alcohol
Parameter
How often do you have a drink containing
alcohol?

How many drinks containing alcohol do you


have on a typical day when you are drinking?

How often do you have 6 or more drinks on


one occasion?

Finding
never

Points
0

monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
1 or 2

1
2
3
4
0

3 or 4
5 or 6
7 to 9
10 or more
never

1
2
3
4
0

less than monthly


monthly
weekly
daily or almost daily
How often during the past year have you found never
that you were not able to stop drinking once
you had started?
less than monthly

1
2
3
4
0

monthly
weekly
daily or almost daily
How often during the past year have you failed never
to do what was normally expected of you
because of drinking?
less than monthly
monthly
weekly
daily or almost daily
How often during the past year have you
never
needed a first drink in the morning to get
yourself going after a heavy drinking session?
less than monthly
monthly
weekly
daily or almost daily
How often during the past year have you had a never
feeling of guilt or remorse after drinking?
less than monthly
monthly
weekly
daily or almost daily
How often during the past year have you been never
unable to remember what happened the night
before because you had been drinking?
less than monthly
monthly
weekly
daily or almost daily
Have you or someone else ever been injured as no
a result of your drinking?
yes, but not in past year
yes, during the last year
Has a relative or friend or a doctor or other
no
health worker been concerned about your
drinking or suggested you cut down?
yes, but not in past year
yes, during the last year
AUDIT score =
= SUM(points for all 10 questions)
Interpretation:

2
3
4
0

1
2
3
4
0

1
2
3
4
0
1
2
3
4
0

1
2
3
4
0
2
4
0

2
4

minimum score: 0
maximum score: 40
A score >= 8 indicates a strong likelihood of hazardous or harmful alcohol use.
NOTE: The AUDIT Clinical Procedure for clinical examination of a patient is described in
the chapter on clinical toxicology.
References:
Allen JP, Columbus M (editors). Assessing Alcohol Problems. A Guide for Clinicians and
Researchers. National Institute on Alcohol Abuse and Alcoholism. NIH 95-3745.
1995. pages 260-265.
Allen JP, Litten RZ, et al. A review of research on the Alcohol Use Disorders
Identification Test (AUDIT). Alcoholism Clin Exp Res. 1997; 21: 613-619.
Babor TF, de la Fuente JR, et al. AUDIT: The Alcohol Use Disorders Identification Test:
Guidelines for use in primary health care. Geneva, Switzerland. World Health
Organization. Publication 89.4. 1989. (also published 1992).
Bohn MJ, Babor TF, Kranzler HR. The Alcohol Use Disorders Identification Test
(AUDIT): Validation of a screening instrument for use in medical settings. J Stud
Alcohol. 1995; 56: 423-432.
McRee B, Babor TF, Church O. Instructor's Manual for Alcohol Screening and Brief
Intervention. Project NEADA. The University of Connecticut School of Nursing.
1991.
18.16.05 The Canterbury Alcoholism Screening Test (CAST)
Overview:
The Canterbury Alcoholism Screening Test (CAST) can be used to detect alcoholism in
hospitalized patients. The authors are from the University of Canterbury in Christchurch,
New Zealand.
NOTE: While this is longer than many of the screening instruments, this seems to do a
good job of covering the major issues without being overly sensitive.
(1) When did you last drink? (Discontinue if the response is "never.")
(2) How much do you normally drink each week?
(3) Have you been in hospital more than once because of accidents?
(4) Have any close family members such as a parent, spouse, brother or sister had
drinking problems?
Thinking over the past 3 months:
(5) Do you drink before lunch fairly often?
(6) After the first glass or two of alcohol do you ever feel a craving for more?
(7) Do you find you are thinking a lot about alcohol?
(8) Do you sometimes drink alcohol even against your doctor's advice?
(9) When you drink a lot of alcohol do you tend to eat less?
(10) In the morning do you sometimes feel that you might be sick (vomit)?

(11) Have you found that your hands have been trembling a lot?
(12) Have you ever used alcohol to get rid of trembling or the feeling that you might be
sick?
(13) Have you ever been criticised at work because of your drinking?
(14) Do you prefer to drink alone?
(15) Do you think you're in worse shape because of your drinking?
(16) Do you ever have a guilty conscience about drinking?
(17) In order to cut down your drinking, have you ever felt it necessary to limit it to
certain occasions or to certain times of the day?
(18) Do you feel you should drink less?
(19) Do you think that without alochol you would have fewer problems?
(20) When you're upset do you drink alcohol to calm down?
(21) Are there times when you'd like to stop drinking?
(22) Would you get along better with your spouse/partner/the people you're closest to if
you didn't drink?
(23) Have you ever deliberately tried to do without any alcohol at all?
(24) Have you ever been told that your breath smells of alcohol?
Clinical assessment
(25) Palpable liver.
(26) Dupuytren's contracture.
(27) Elevated serum GGT.
(28) Elevated AST.
where:
For question 2: Discontinue if response for men is < 5 and for women < 3.
For question 3: all types of accidents.
In the implementation I did not stop the questionnaire if the responses to the first 2
questions indicated no or low alcohol intake. This was too time consuming to
implement but is doable.
Scoring:
A response in question 2 of >= 36 for men or >= 16 in women is given 1 point.
A positive response for questions 3 to 28 is given 1 point.
total score =
= SUM(points for the 27 questions scored)
Interpretation:
minimum score: 0
maximum score: 27
A group of known alcoholics all had a score >= 3 and 98% has a score >= 5.
The presence of a given score does not mean that the person is alcoholic, only that
further investigation is warranted.
Performance:

Only 1.6% of the control non-alcoholic group were identified with the CAST.
95% of patients classified as alcoholic by the short MAST were identified by CAST.
CAST identified as problem drinkers some patients with a short MAST score of 0 or
1 (who showed craving or concern on their level of drinking).
References:
Elvy GA, Wells JE. The Canterbury alcoholism screening test (CAST): a detection
instrument for use with hospitalised patients. New Zealand Medical Journal. 1984;
97: 111-115.
18.17 Evaluation of Substance Abuse
18.17.01 Criteria for Substance Dependence
Overview:
Substance dependence is a maladaptive pattern in a person's use of a substance, indicating
impaired control over the its use and associated with clinically significant impairment or
distress.
Criteria:
(1) 3 or more of the following 7 findings,
(2) occurring at any time in the same 12 month period.
If Findings 1 or 2 are present, then the person is said to have physiological dependence.
Findings
(1) tolerance: defined by at least one of the following
(a) a need for markedly increased amounts of the substance to achieve intoxication or
the desired effect
(b) continued use of the same amount of the substance has a markedly diminished
effect
(2) withdrawal: defined by at least one of the following
(a) characteristic withdrawal syndrome for the substance
(b) use of the substance or a closely related compound to relieve or avoid the
withdrawal symptoms
(3) The substance is taken in larger amounts or over a longer period than was intended.
(4) There is a persistent desire or there are unsuccessful efforts to cut down or control
substance use.
(5) A great deal of time is spent in activities necessary to obtain the substance, use the
substance, or recover from its effects.

(6) Important social, occupational, or recreational activities are given up or reduced


because of substance use.
(7) The substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or made worse
by the substance.
Comments
In DSM-III a person needed to show tolerance and/or withdrawal symptoms to be
classed as having a substance dependency. For DSM-IV, a broader definition was
used to encompass substances not causing phsyiological dependence, and to include
compulsive use of a substance.
References:
American Psychiatric Association. Diagnostic Criteria from DSM-IV. 1994. pages 108109
Frances A, First MB, Pincus HA. DSM-IV Guidebook. American Psychiatric Press, Inc.
1995. pages 131-134.
18.17.02 Evaluating Adolescent Substance Abuse
Overview:
Substance abuse in adolescents can be simple experimentation, or an indication of a
serious underlying behavioral condition. A simple score can help assess the significance of
the substance use.
Parameters
(1) age
(2) sex
(3) family history of drug abuse
(4) setting for use
(5) patient's affect before substance use
(6) school performance
(7) use before driving
(8) history of accidents
(9) time of week when used
(10) type of substance abused
Variable
age

Finding
> 15 years of age
<= 15 years of age
sex
male
female
family history of drug abuse no
yes

Points
0
1
0
1
0
1

setting of drug use


affect before drug use
school performance

use before driving


history of accident
time of week

type of substance

in group
alone
happy
sad
good or improving
always poor
recently poor
none
yes
no
yes
weekend
weekdays after school
before school
marijuana, beer, wine
hallucinogens,
amphetamines
whiskey, opiates, cocaine,
barbiturates

0
2
0
2
0
1
2
0
2
0
2
0
1
2
0
1
2

score =
= SUM(points for variable findings)
Interpretation:
minimum score: 0
maximum score: 17 (although reference says 18)
Score
Assessnent
0-3
less worrisome
4-8
serious
9 - 17
very serious
(breakpoints in reference are 0-3, 3-8, and 8 to 17)
References:
Nelson WE, Behrman RE, et al (editors). Nelson Textbook of Pediatrics, 15th Edition.
WB Saunders Company. 1996. Chapter 105: Substance abuse. pages 543-548. Table
105-1, page 544.
18.17.03 Screening for Adolescent Substance Abuse Using the CRAFFT
Questionnaire
Overview:
The CRAFFT questionnaire is a brief screening instrument to detect substance abuse in
adolescents. This was developed at the Harvard Medical School in Boston.

Sources for questions


Drug and Alcohol Problem Quickscreen (DAP): C
Problem-Oriented Screening Instrument for Teenagers (POSIT): R, F1, F2
RAFFT screen from Project ADEPT: R, A, T
Questionnaire
(C) Have you ever ridden in a car driven by someone (including yourself) who was high or
had been using alcohol or drugs?
(R) Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
(A) Do you ever use alcohol or drugs while you are by yourself (alone)?
(F) Do you ever forget things you did while you were using alcohol or drugs?
(F) Do your family or friends ever tell you that you should cut down on your driking or
drug use?
(T) Have you ever gotten into trouble while you were using alcohol or drugs?
responses: yes or no
score =
= SUM(number of "yes" responses)
Interpretation:
minimum score: 0
maximum score: 6
A score >= 2 was 92.3% sensitive and 82.1% specific for long term treatment need.
References:
Knight JR, Shrier LA, et al. A new brief screen for adolescent substance abuse. Arch
Pediatr Adolesc Med. 1999; 153: 591-596.
18.17.04 Fagerstrom Test for Nicotine Dependence
Overview:
Smokers with high level nicotine dependence can be identified using the Fagerstrom test.
Question
How soon after you wake up do you smoke
your first cigarette?

Finding
<= 5 minutes

Points
3

6 30 minutes

Do you find it difficult to refrain from


smoking in places where it is forbidden (in
church, in the library, in a cinema)?

31 60 minutes
>= 61 minutes
yes

no
Which cigarette would you hate most to give the first in the
up?
morning
any other
How many cigarettes per day do you smoke? <= 10
11 20
21- 30
>= 31
Do you smoke more frequently during the
yes
first hours after waking than during the rest
of the day?
no
Do you smoke if you are so ill that you are in yes
bed most of the day?
no
from Table 54-12, Ellenhorn

1
0
1

0
1
0
0
1
2
3
1

0
1
0

nicotine dependence score =


= SUM(poitns for the 6 questions)
Interpretation:
minimum score: 0
maximum score: 10
A score > 6 indicates a high degree of nicotine dependence and is associated with more
severe withdrawal symptoms, greater difficulty in quitting, and possibly the need for
a higher dose of nicotine in smoking cessation materials.
References:
Ellenhorn MJ. Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human
Poisoning. Williams & Wilkins. 1997., Second Edition. Chapter 54: Household
poisonings. pages 1078-1123 (Table 54-12, page 1113).
Heatherton TF, Kozlowski LT, et al. The Fagerstrom test for nicotine dependence: A
revision of the Fagerstrom Tolerance Questionnaire. Br J Addict. 1991; 86: 11191127.
Henningfield JE. Nicotine medications for smoking cessation. N Engl J Med. 1995; 333:
1196-1203.
18.17.05 Problem Severity Index (PSI) for Patients with Drug Dependence
Overview:

The Problem Severity Index (PSI) can be used to evaluate patients who are drug
dependent. This can help identify psychosocial problems in the person's life that
encourage drug use or that thwart recovery attempts. The authors are from Texas
Christian University in Fort Worth.
Components:
(1) multiple drug use (use of any 3 or more drug categories in the past year)
(2) alcohol dependence (by either DSM-III criteria or self-reported daily alcohol
consumption)
(3) criminally active (on probation or parole, awaiting trial, case pending, or a period of
weekly involvement in illegal activities during the past year)
(4) unemployed (never worked at a full-time job during the past year)
(5) low social support (having several family members or close friends who use illegal
drugs, or who were incarcerated during the past year)
(6) depression or anxiety (including suicidal thoughts or acts)
(7) no private insurance
where:
I would assume that alcohol would be included as one of the drug categories for multiple
drug use.
Problem Status
absent
present

Points
0
1

PSI =
= SUM(points for all 7 components)
Interpretation:
minimum score: 0
maximum score: 7
The higher the score, the greater the number of problems that can reduce the chances of
overcoming drug dependence.
In patients with cocaine dependence, a low level of problems was associated with a
lower relapse rates. A person with a high problem level often benefited from a long
term residential recovery program.
PSI
0 to 3
4 or 5
6 or 7

Problem Level
low
medium
high

References:
Simpson DD, Joe GW, et al. A national evaluation of treatment outcomes for cocaine
dependence. Arch Gen Psych. 1999; 56: 507-514.

18.18 Evaluation of Abusive Behavior


18.18.01 Types of Abusive Behavior
Overview:
A person who abuses others may use one or more types of behavior to achieve
domination.
Behavior
destructive of furniture or possessions
injury of pets
withholding of money, car or health insurance
refusal to pay bills
sabotaging a person's attempts to work or go to school
uninvited visits, telephone calls or letters
stalking
embarassement of victim in public
slapping, punching, kicking, pinching, biting, grabbing,
choking, restraining or pulling hair
sexual assault
oral, implicit or direct threats or criticism
use of weapons
throwing objects
standing in doorway or cornering victim during arguments
shouting, swearing
driving recklessly
restricting and tracking activities
restricting and tracking telephone calls
threats to seek custody or kidnap children
threats to kill victim or self

Type
aggressive
controlling or coercive

harassing

destructive

intimidating

isolating
threatening

References:
Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med. 1999; 341: 886-892.
Warshaw C, Ganley A. Improving the health care response to domestic violence: A
resource manual fo rhealth care providers. Family Violence Prevention Fund. 1995.
18.19 Evaluation of Manic States
18.19.01 Manic Rating Scale
Overview:
The Manic Rating Scale (MRS) can be used to evaluate patients with manic symptoms.
Parameters:

(1) elevated mood


(2) increased motor activity and energy
(3) sexual interest
(4) sleep
(5) irritability
(6) speech (rate and amount)
(7) language-thought disorder
(8) content
(9) disruptive-aggressive behavior
(10) appearance
(11) insight
Parameter
elevated mood

increased motor
activity and energy

sexual interest

sleep

Finding
absent
mildly or possibly increased on
questioning
definite subjective elevation; optimistic;
self-confident; cheerful; appropriate to
content
elevated; inappropriate to content;
humorous
euphoric; inappropriate laughter; singing
absent
subjectively increased
animated; gestures increased
excessive energy; hyperactive at times;
restless (can be calmed)
motor excitement; continuous
hyperactivity (cannot be calmed)
normal; not increased
mildly or possibly increased
definite subjective increase on questioning
spontaneous sexual content; elaborates on
sexual matters; hypersexual by self report
overt sexual acts (towards patients, staff or
interviewer)
reports no decrease in sleep
sleeping less than normal amount by up to
1 hour
sleeping less than normal by more than 1
hour
reports decreased need for sleep
denies need for sleep

Points
0
1
2

3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4

irritability

speech (rate and


amount)

language-thought
disorder

content

disruptive-aggressive
behavior

appearance

absent
subjectively increased
irritable at times during interview; recent
episodes of anger or annoyance on ward
frequently irritable during interview; short,
curt throughout
hostile; unco-operative; interview
impossible
no increase

0
2
4

feels talkative
increased rate and amount at times; verbose
at times
push; consistently increased rate and
amount; difficult to interrupt
pressured; uninterruptible; continuous
speech
absent

2
4

circumstantial; mild distractibility; quick


thoughts
distractible; loses goal of thought; changes
topics frequently; racing thoughts
flight of ideas; tangentiality; difficult to
follow; rhyming; echolalia
normal
questionable plans, new interests
special projects; hyperreligious
grandiose or paranoid ideas; ideas of
reference
delusions; hallucinations
absent, co-operative

sarcastic; loud at times; guarded


demanding; threats on ward
threatens interviewer; shouting; interview
difficult
assaultive; destructive; interview
impossible
appropriate dress and grooming
minimally unkept
poorly groomed; moderately dishevelled;
overdressed
dishevelled; partly clothed; garish make-up

2
4
6

6
8
0

6
8
0

2
3
0
2
4
6
8
0

8
0
1
2
3

insight

completeley unkept; decorated; bizarre


garb
present; admits illness; agrees with need
for treatment
admits that possibly ill
admits behavior change but denies illness
admits possible change in behavior but
denies illness
denies any behavior change

4
0
1
2
3
4

manic rating scale =


= SUM(points for all 11 parameters)
Interpretation:
minimum score: 0
maximum score: 59
The score correlates strongly with the severity of the mania.
References:
Fristad MA, Weller EB, Weller RA. The Mania Rating Scale: Can it be used in children?
A preliminary report. J Am Acad Child Adolesc Psychiatry. 1992; 31: 252-257.
Young RC, Biggs JT, et al. A rating scale for mania: Reliability, validity and sensitivity.
Br J Psychiatry. 1978; 133: 429-435.
18.19.02 Manic State Rating Scale
Overview:
The Manic State Rating Scale can be used to evaluate manic patients. The scale can be
followed over time to monitor the patient's state and response to interventions. The scale
was developed at the National Institute of Mental Health in Bethesda, Maryland.
Procedure:
The patient is observed for 26 behaviors.
Each behavior is assessed for its frequency and intensity, each of which is assigned a
point score.
The score for each behavior is the product of the points for frequency and intensity.
The patient:
(1) looks depressed
(2) is talking
(3) moves from one place to another
(4) makes threats
(5) has poor judgment
(6) dresses inappropriately
(7) looks happy and cheerful

(8) seeks out others


(9) is distractable
(10) has grandiose ideas
(11) is irritable
(12) is combative and destructive
(13) is delusional
(14) verbalizes depressive feelings
(15) is active
(16) is argumentative
(17) talks about sex
(18) is angry
(19) is careless about dress and grooming
(20) has diminished impulse control
(21) verbalizes feelings of well-being
(22) is suspicious
(23) makes unrealistic plans
(24) demands contact with others
(25) is sexually preoccupied
(26) jumps from one subject to another
Observation
frequency

intensity

Level
none
infrequent
some
much
most
all
very minimal
minimal
moderate
marked
very marked

Points
0
1
2
3
4
5
1
2
3
4
5

score for each behavior =


= (points for frequency) * (points for intensity)
manic state rating scale =
= SUM(score for all 26 behaviors)
Interpretation:
minimum score for each observation: 0
minimum score for each observation: 25
minimum manic state rating scale: 0
maximum manic state rating scale: 650
The higher the score, the more marked the manic state.

The items best characterizing a change in manic severity: 3, 5, 9, 15, 18, 26


References:
Beigel A, Murphy DL, Bunney WE Jr. The Manic-State Rating Scale. Arch Gen
Psychiat. 1971; 25: 256-262.
18.19.03 Longitudinal Rating Scale of Petterson et al for the Manic State
Overview:
Petterson et al developed a longitudinal rating scale for the manic state. It can be used to
monitor the manic patient over time and evaluate response to therapeutic interventions. It
was developed at the Karolinska Institute in Stockholm, Sweden.
Parts:
(1) ratings of individual features
(2) global ratings
Individual Feature Rating
Parameters:
(1) motor activity: This item concerns an increase in general mobility as can be observed
in mimics, gestures, gait and other intentional movements. Consideration is given to
quantity as well as to rate of movements.
(2) pressure of speech: This items concerns a quantitative evaluation of the patient's
verbal activity as observed during the interview.
(3) flight of ideas: This item is related to flow of associations as can be inferred from the
patient's talk during the interview.
(4) noisiness: This item concerns the level of noise the patient induces as can be noticed
during the interview.
(5) aggressiveness: This item rates aggressiveness in terms of the patient's verbal and
behavioral expressions. It is rated with regard to intensity and frequency.
(6) orientation
(7) elevated mood: This item is related to the level of mood the patient expresses in
his/her mimics, selection of conversation subjects and personal view of his/her mood.

Parameter
motor activity

Finding
Quiet or slow movements. Few gestures.
Ordinary or slightly prolonged latency at the
initiation of activity.
Ordinarily changing rate and amount of
movements. Only short periods of quiescence
occur

Points
1

pressure of speech

flight of ideas

noisiness

Vivid mimics and gait. Gestures and movements


are abundant without being exaggerated or
especially remarkable.
Exaggerated, extensive and/or rapid movements
occur repeatedly. Gesticulation is conspicuous.
The patient leaves his/her chair on single
occasions during the interview.
Continuous motor activity. The patient cannot be
persuaded to remain in a quiet sitting or
recumbent position.
Gives laconic answers. Expresses few sentences
spontaneously.
Gives adequate answers without being word-rich.
Talks without hindrance.
Expresses spontaneously longer sentences. Gives
word-rich answers. Rapid speech.
Very talkative. Utters spontaneously detailed,
word-rich statements, interrupts the interviewer
on single occasions.
Directs the conversation completely. It is
impossible to cutoff the patient's talk. The
patient talks uninterruptedly without paying
attention to stimuli from the interviewer.
The patient's talk is coherent and the connection
between the sentences is adquate. Few
associations.
Free, lively associations with a tendency towards
deviation from the subject.
Rapid flow of associations with single occurrence
of unusual associations as induced by sound or
other stimuli.
Associations are rich and rapid and there is an
abundance of associations induced by visual and
auditory stimuli during the interview.
The conversation often deviates with regard to the
subject, and the patient has great difficulty in
continuing a logical conversation due to new
associations.
The patient talks with a low or modulated voice
level.
Speaks clearly and on single occasions loudly.
Regulates his/her noise level according to his/her
environment.
Speaks loudly all the time but cannot be regarded
as disturbing.

1
2
3
4

2
3

1
2

aggressiveness

orientation

elevated mood

The level of noise the patient makes can be heard


at some distance. The patient does not regulate
the level of noise with regard to his/her
environment. The amount of noise the patiend
induces is disturbing.
The patient shouts and roars more or les
constantly and is very disturbing.
No noticeable signs of aggressiveness.
On provocation the patient is slightly irritable.
On single occasions aggressive statements in
relation to events occurring outside the interview.
The conversation during the interview occurs
quitely for long periods.
Verbal aggressiveness repeatedly without
provocation. Quarrels, leaves the chair, but can be
calmed.
Threatening, destructive acts, physical violence
during the interview.
Clear sensorium. Adequate orientation.
Slight or infrequent occurrence of clouded
sensorium.
Obvious disorientation during most of the
interview.
A neutral mood. Modulated changes between
higher and lower mood with regard to the subject
of conversation.
The patient has an optimistic, self-confident
attitude which appears to be adequate in relation
to his/her situation.
The patient has an optimistic, happy or selfconfident attitude without regard to the subject of
speech. The mood is elevated as can be noticed
from the selection of subjects for conversation
and facial expression and gesture.
Markedly elevated mood or exaggerated selfconfidence without relation to subject of
conversation. Intermittently an intense feeling of
well-being.
A continuous feeling of extreme well-being or
marked emotional exaltation. Maximal selfconfidence.

5
1
2
3

5
1
2
3
1

Global Ratings
Parameter

Finding

Points

manic state

change in manic state since


previous rating

no signs of hypomanic or manic state


possibly hypomanic, optimistic attitude
hypomanic
manic behavior
markedly manic behavior
marked deterioration

1
2
3
4
5
1

slight deterioration
unchanged
slight improvement
marked improvement

2
3
4
5

where:
The points assigned for the global rating of change in state seems reversed from what I
would expect.
total score for individual features =
= SUM(points for individual features)
Interpretation:
minimum score for individual features: 7
maximal score for individual features: 33
The higher the score for individual features, the more manic the clinical picture.
Effective drug treatment is associated with (1) a decrease in the score for individual
features, (2) a decrease in the global rating for manic state, and (3) an increase in the
global rating for change from previous ratings.
References:
Petterson U, Fyro B, Sedvall G. A new scale for the longitudinal rating of manic states.
Arch Psychiat Scand. 1973; 49: 248-256.
18.19.04 Manic State Checklist for Nurses
Overview:
Beigel et al developed a symptom checklist for nurses caring for manic patients. It was
developed at the National Institute of Mental Health in Bethesda, Maryland.
Symptoms:
(1) hyperverbal
(2) hyperactive
(3) distractable
(4) grandiose
(5) euphoric-elated
(6) manipulative
(7) physically aggressive

(8) denial
(9) seeks out others
(10) angry
(11) irritable
(12) undressing
(13) sexual preoccupation
(14) insensitive to others
Scoring:
absent: 0 points
present: 1 point
symptom score =
= SUM(number of symptoms present)
Interpretation:
minimum symptom score: 0
maximum symptom score: 14
Patients with high or increasing symptom scores may need a more in-depth evaluation.
References:
Beigel A, Murphy DL, Bunney WE Jr. The Manic-State Rating Scale. Arch Gen
Psychiat. 1971; 25: 256-262. (Figure 2, page 260)
18.20 Suicide and Self-Harm
18.20.01 Scale for Suicide Ideation of Beck et al.
Overview:
The Scale of Suicide Ideation consists of 19 items which can be used to evaluate a
patient's suicidal intentions. The scale can be used to identify a patient at significant risk
and to monitor a patient's response to inverventions over time. The authors are from the
Universities of Pennsylvania and Pittsburgh.
Item
wish to live

wish to die

reasons for living/dying

Response
moderate to strong
weak
none
none
weak
moderate to strong
for living outweigh for dying
about equal
for dying outweigh for living

Points
0
1
2
0
1
2
0
1
2

desire to make active


suicide attempt

none

weak
moderate to strong
passive suicidal desire
would take precautions to save life
would leave life/death to chance
would avoid steps necessary to save or
maintain life
time dimension: duration of brief, fleeting periods
suicide ideation/wish
longer periods
continuous (chronic) or almost continuous
time dimension: frequency rare, occasional
of suicide
intermittent
persistent or continuous
attitude toward
rejecting
ideation/wish
ambivalent, indifferent
accepting
control over suicidal
has sense of control
action/acting-out wish
unsure of control
has no sense of control
deterrents to active attempt would not attempt because of a deterrent
some concern about deterrents
minimal or no concern about deterrents
reason for contemplated
to manipulate the environment; get
attempt
attention or revenge
combination of desire to manipulate and to
escape
escape, surcease, solve problems
method: specificity or
not considered
planning of complemplated
attempt
considered but details not worked out
details worked out and well-formulated
method: availability or
method not available or no opportunity
opportunity for
contemplated attempt
method would take time or effort;
opportunity not readily available
method and opportunity available

0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0

1
2
0

1
2

sense of "capability" to
carry out attempt

expectancy/anticipation of
actual attempt

actual preparation for


contemplated attempt

suicide note

final acts in anticipation of


death

deception or concealment
of contemplated suicide

furture opportunity or availability of


method anticipated
no courage, too weak, afraid, incompetent

unsure of courage or competence


sure of competence, courage
no

1
2
0

uncertain, not sure


yes
none

1
2
0

partial
complete
none
started but not completed; only thought
about
completed
none

1
2
0
1

thought about or made some arrangements


made definite plans or completed
arrangements
revealed ideas openly

1
2

held back on revealing


attempted to deceive, conceal or lie

1
2

2
0

where:
"time dimension: frequency of suicide": I have changed this to "frequency of suicidal
thoughts" in implementation
deterrents to active attempt include family, religion or irreversibility of the action
partial preparation for contemplated attempt includes starting to collect pills; completed
preparation includes complete pill collection or a loaded gun
final acts in anticipation of death include insurance and will
scale =
= SUM(points for all 19 items)
Interpretation:
minimum score: 0
maximum score: 38
A higher score indicates a greater intention or ideation for suicide.

Item subsets can be used to identify 3 factors associated with suicide risk (Table 4, page
350, scores > 0.50):
active suicidal desire (10 items: wish to live, wish to die, reasons, desire for active
attempt, passive desire, duration, frequency, attitude toward thoughts, deterrents,
reason, expectancy)
specific plans (3 items: method planning, method opportunity, actual preparation)
passive suicidal desire (3 items: passive suicide desire, sense of capability,
deception/concealment)
Performance:
inter-rater reliability: 83%
internal reliability with Cronbach's alpha: 89%
findings correlate well with other measures of depression
References:
Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: The scale of suicide
ideation. J Consult Clin Psychology. 1979; 47: 343-352.
Beck AT, Steer RA, Rantieri WF. Scale for suicide ideation: Psychometric properties of a
self-report version. J Clin Psychology. 1988; 44: 499-505.
18.20.02 Risk Factors for Suicide in Adults
Overview:
Certain risk factors can help identify adults at greater risk for committing suicide.
Increased risk for suicide is associated with:
(1) male gender
(2) widowed, divorced or single (not married)
(3) lack of or recent loss of social supports
(4) recent loss of employment (unemployed)
(5) fall in social and/or economic status
(6) presence of psychiatric illness (major affective disorder, schizophrenia, personality
disorder, other), especially when mixed (major psychiatric illness and personality
disorder)
(7) physical illness
(8) family history of suicide
(9) psychological turmoil and/or high level of hopelessness
(10) previous attempt(s) at suicide
(11) alcohol or drug abuse
(12) presence of firearms
where:
Major affective disorders at risk include psychosis and bipolar disorder.
Severe mental illness may underly the patient's socioeconomic problems.
References:

Jacobs DG. A 52-year-old suicidal man. JAMA. 2000; 283: 2693-2699. (Table 2, page
2694).
Klerman GL. Clinical epidemiology of suicide. J Clin Psychiatry. 1987; 48 (Suppl 12):
33-38.
Mann JJ. Psychobiologic predictors of suicide. J Clin Psychiatry. 1987; 48 (Suppl 12):
39-43.
Mortensen PB, Agerbo E, et al. Psychiatric illness and risk factors for suicide in
Denmark. Lancet. 2000; 355: 9-12.
18.21 Seasonal Affective Disorder (SAD)
18.21.01 Diagnostic Criteria for Seasonal Affective Disorder
Overview:
The Seasonal Affective Disorder (SAD) is a form of bipolar affective or recurrent
depressive disorder with episodes of varying severity that vary based on the season of
the year.
Types based on season:
(1) winter (most common form)
(2) summer
(3) other
Symptoms (frequent or fairly frequent, Panel 2, page 1371, Partonen):
social withdrawal
decreased activity
sadness
anxiety
carbohydrate craving
decreased libido
poor quality of sleep
increased sleep
irritability
increased weight
increased appetite
Other psychological conditions found in patients with SAD:
eating disorders
phobias and anxiety disorders
avoidant personality disorder
ICD-10 Provisional Criteria:
(1) 3 or more episodes of an affective disorder for 3 or more consecutive years
(2) onsets and remissions within a particular 90 day period of the year
(3) seasonal episodes that substantially outnumber non-seasonal episodes

where:
Since seasons vary depending on latitude, I am not sure that limiting onset and remission
to a 90 day period is always feasible.
References:
Partonen T, Lonnqvist J. Seasonal affective disorder. Lancet. 1998; 352: 1369-1374.
World Health Organization. The ICD-10 classification of mental and behavioural
disorders: diagnostic criteria for research. Geneva. WHO. 1993.
18.22 Violent and Aggressive Behaviors
18.22.01 Rating Scale of Delgado-Escueta et al for Aggressive Behavior
Overview:
Aggressive and violent behavior may be rated according to the scale described by DelgadoEscueta et al. The scale was developed at an International Workshop on Aggression and
Epilepsy held at Bethesda, Maryland in 1980.
Terms used: aggression and violence are not synonomous but may overlap
Aggression: physical action that may or may not be directed against a target
Violence: aggressive act directed against a target
Type of Aggression
nondirected aggressive
motion

violence to property
threatening violence to a
person
mild violence to a person

moderate violence to a
person

severe violence to a person

from page 712

Example
kicking, flailing, boxing,
hitting or other acts not
directed to a person or
object
physical force that destroys
an inanimate object
includes gestures, shouting
and spitting
force against a person
without inflicting physical
harm, such as pushing or
shoving
physical force that
substantially harms another
person, such as hitting with
the fist or scratching
physical force damaging or
seriously endangering the
life of a person, or actual
killing of a person

Rating
1

2
3
4

Limitation:
Aggression to an animal is not included in the rating hierarchy. It probably should be
rated more than aggression to inanimate objects but rated slightly less than the same
degree directed against a person (although some would think that the rating should be
the same).
I am not sure if a very destructive act against property should be rated the same as a
minor action.
I am not sure if obscene gestures fit into the scale (? rating 0).
References:
Delgado-Escueta AV, Mattson RH, et al. The nature of aggression during epileptic
seizures. New England J Med. 1981; 305: 711-716.
18.23 Dementia and Behavioral Problems in the Elderly and Institutionalized
Persons
18.23.01 The Nursing Home Behavior Problem Scale
Overview:
The Nursing Home Behavior Problem Scale consists of a 29 item inventory of behavior
problems encountered in nursing homes and other chronic care facilities. The scale can be
used to monitor the severity of the behavioral problems manifested by the resident. The
authors are from Vanderbilt University, the University of Texas Health Science Center
and the Audie L. Murphy Memorial Veterans Hospital.
Directions:
Please rate this resident's behavior during the last 3 days only. Indicate your choice by
circling a number for each item, using this key.
Frequency
never
sometimes
often
usually
always

Points
0
1
2
3
4

Behaviors:
(1) resists care
(2) becomes upset or loses temper easily
(3) enters others rooms inappropriately
(4) awakens during the night
(5) talks, mutters, or mumbles to him/herself
(6) tries to hurt him/herself
(7) refuses care
(8) fights or physically aggressive; hits, slaps, kicks, bites, spits, pushes, pulls

(9) fidgets, is unable to sit still, restless


(10) has difficulty falling asleep
(11) goes to the bathroom in inappropriate places (not incontinence)
(12) says things that do not make sense
(13) damages or destroys things on purpose
(14) screams, yells, or moans loudly
(15) argues, threatens, or curses
(16) tries to get in or out of wheelchair, bed or chair unsafely
(17) asks or complains about her or his health, even though it is unjustified
(18) has inappropriate sexual behavior
(19) sees or hears things that are not there
(20) disturbs others during the night
(21) wanders, tries to escape or go to off-limits places
(22) accuses others of things that are not true
(23) asks for attention or help, even though it is not needed
(24) is uncooperative
(25) paces, walks or moves in wheelchair aimlessly back and forth
(26) tries to escape physical restraints
(27) complains or whines
(28) does something over and over, even though it doesn't make sense
(29) tries to things that are dangerous
scale score =
= SUM(points for all 29 items)
Interpretation:
minimum score: 0
maximum score: 116
The higher the score, the more serious the behavioral problem manifested.
A higher score correlates with mental impairment, with use of sedative drugs or physical
restraints.
Performance:
interrater correlation: 0.754 to 0.827 in study populations
correlation with other scales: -0.747 with NOSIE scale, 0.911 with CMAI scale
References:
Ray WA, Taylor JA, et al. The Nursing Home Behavior Problem Scale. J Gerontol (Med
Sci). 1992; 47: M9-M16.
18.23.02 Functional Dementia Scale (FDS)
Overview:
The Functional Dementia Scale (FDS) can be used to evaluate the behavior of a patient
with dementia. It consists of 20 items divided into 3 subscales. It can be monitored over

time and can be used to assess the effectiveness of interventions. The authors are from
Duke University in Durham, North Carolina.
Subscales:
(1) activities of daily living
(2) orientation
(3) affect
Behaviors (20):
(1) has difficulty in completing simple tasks on own (e.g., dressing, bathing, doing
arithmetic)
(2) spends time either sitting or in apparently purposeless activity
(3) wanders at night or needs to be restrained to prevent wandering
(4) hears things that are not there
(5) requires supervision or assistance in eating
(6) loses things
(7) appearance is disorderly if left to own devices
(8) moans
(9) cannot control bowel function
(10) threatens to harm others
(11) cannot control bladder function
(12) needs to be watched so doesn't injury self (e.g., by careless smoking, leaving the
stove on, falling)
(13) destructive of materials around him or her (e.g., breaks furniture, throws food trays,
tears up magazines)
(14) shouts or yells
(15) accuses others of doing him or her bodily harm or stealing possessions when you are
sure that the accusations are not true
(16) is unaware of limitations imposed by illness
(17) becomes confused and does not know where he/she is
(18) has trouble remembering
(19) has sudden changes of mood (e.g., gets upset, angered, cries easily)
(20) if left alone, wanders aimlessly during the day or needs to be restrained to prevent
wandering
Frequency
none
little of the time
some of the time
good part of the time
most of the time
all of the time

Grading
1
1
2
3
4
4

activities of daily living subscale =


= SUM(points for items 1, 2, 5, 7, 9, 11 and 12)

orientation subscale =
= SUM(points for item 3, 6, 16, 17, 18 and 20)
affect subscale =
= SUM(points for items 4, 8, 10, 13, 14, 15, and 19)
total functional dementia scale =
= SUM(points for all 20 behaviors)
Interpretation:
minimum activities of daily living and affect subscales: 7
minimum orientation subscale: 6
minimum total score: 20
maximum activities of daily living and affect subscales: 28
maximum orientation subscale: 24
maximum total score: 80
The higher the score, the more problematic the patient's behavior.
Performance:
internal consistency: Cronbach's alpha 0.90
test-retest correlation: 0.88
Pearson correlation coefficient with the SET test: 0.48
Pearson correlation coefficient with the SPMSQ: 0.39 (standard cognitive measures tend
to be insensitive to the functional disabilities and management problems found with
dementia)
References:
Moore JT, Bobula JA, et al. A functional dementia scale. J Family Practice. 1983; 16:
499-503.
18.23.03 Agitated Behavior Scale (ABS)
Overview:
The Agitated Behavior Scale (ABS) can be used to evaluate behavioral problems in
institutionalized patients with dementia, head trauma or other condition. Tracking the
score over time can aid in determining if the patient is improving or deteriorating and how
effective interventions have been. The primary author is from the Ohio State University
in Columbus.
Instructions:
At the end of the observation period, indicate whether the behavior described in each item
was present, and, if so, to what degree: slight, moderate or severe. Use the following
numerical values and criteria for your ratings. Do not leave blanks.
Behavioral Items:

(1) short attention span, easy distractibility. inability to concentrate


(2) impulsive, impatient, low tolerance for pain or frustration
(3) uncooperative, resistant to care, demanding
(4) violent and/or threatening violence towards people or property
(5) explosive and/or unpredictable anger
(6) rocking, rubbing, moaning, or other self-stimulating behavior
(7) pulling at tubes, restraints, etc.
(8) wandering from treatment areas
(9) restlessness, pacing, excessive movement
(10) repetitive behaviors, motor and/or verbal
(11) rapid, loud or excessive talking
(12) sudden changes of mood
(13) easily initiated or excessive crying and/or laughter
(14) self-abusiveness, physical and/or verbal
Rating
absent
present to a slight degree
present to a moderate degree
present to an extreme degree

Points
1
2
3
4

total score =
= SUM(points for all 14 behavioral items)
Interpretation:
minimum score: 14
maximum score: 56
The higher the score, the greater the behavioral problems demonstrated by the patient.
percent of maximal score =
= (((total score) 14) / 42) * 100%
References:
Bogner JA, Corrigan JD, et al. Rating scale analysis of the Agitated Behavior Scale. J
Head Trauma Rehabil. 2000; 15: 656-669.
Corrigan JD. Development of a scale for assessment of agitation following traumatic brain
injury. J Clin Exp Neuropsychol. 1989; 11: 261-277.
18.24 Electroconvulsive Therapy (ECT)
18.24.01 Conditions Associated with Adverse Events Following Electroconvulsive
Therapy
Overview:

Electroconvulsive therapy (ECT) may be associated with adverse events. There is no


absolute contraindication to the procedure. However, the decision to administer therapy
should be based on a careful evaluation of potential benefits and risks from the procedure
versus the potential risks if the procedure is not performed.
Conditions associated with an increased risk for an adverse outcome from ECT:
(1) severe cardiovascular disease: recent myocardial infarction, unstable angina, poorly
compensated congestive heart failure, and severe valvular disease
(2) aneurysms or vascular malformations
(3) conditions resulting in increased intracranial pressure (tumors, other space occupying
lesions)
(4) recent cerebral infarction
(5) severe pulmonary disease, including chronic obstructive pulmonary disease (COPD),
asthma, or pneumonia
(6) patients classified as ASA level 4 (poor health with at least 1 incapacitating diseases)
or 5 (morbibund with danger of imminent death)
A patient with one or more of these conditions should be carefully evaluated prior to
administration of therapy:
(1) Medications should be administered or adjusted to reduce the risk for an adverse event
(prevention of elevated or depressed blood pressure, hyperthyroidism,
bronchodilators, etc.)
(2) Insertion of a pacemaker may be an aid for a patient with cardiac dysrhythmia.
(3) Diabetic may require careful monitoring of blood glucose levels during the procedure.
(4) Electrolyte disorders should be corrected prior to therapy.
(5) The patient should give informed consent based on an accurate presentation of
potential risks and benefits.
References:
Weiner RD, Coffey CE, and other members of the American Psychiatric Association
Committee on Electroconvulsive Therapy, Second Edition. American Psychiatric
Association. 2001. Chapter 3: Medical conditions associated with substantial risk,
pages 27-30; Chapter 4: Use of electroconvulsive therapy in special populations,
pages 31-58.
18.24.02 Indications for Use of Electroconvulsive Therapy
Overview:
Electroconvulsive therapy (ECT) can be an effective method of treating some patients
with severe psychiatric disorders, especially when drug therapy has not been effective or
has had serious adverse effects.
Indications for the use of ECT:
(1) Severe depression when
(a) other treatments are not effective.
(b) other treatments cannot be used due to serious side effects.

(c) there is a need for a rapid response and other treatments cannot work fast enough
to meet the needs of the clinical situation.
(d) it is the patient's preference.
(e) there is a history of a good response to ECT in the past associated with a poor
response to medication.
(2) Mania
(3) Psychotic exacerbation in a patient with schizophrenia
(a) if the onset has been an abrupt or recent.
(b) catatonia present.
(c) history of favorable response in the past.
(4) Delerium, psychosis or catatonia associated with a toxic or metabolic condition.
References:
Pace B, Lynm C, Glass RM. JAMA Patient Page: Treating depression with
electroconvulsive therapy. JAMA. 2001; 285: 1390.
Weiner RD, Coffey CE, and other members of the American Psychiatric Association
Committee on Electroconvulsive Therapy, Second Edition. American Psychiatric
Association. 2001. Chapter 2: Indications for use of electroconvulsive therapy. pages
5-25.
18.25 Screening for Mental Disorders in Primary Care
18.25.01 The Patient Questionnaire Format for PRIME-MD
Overview:
The PRIME-MD (PRIMary care Evaluation of Mental Disorders) questionnaire is a tool
for identifying common mental health disorders in the primary care setting. The patient is
given the questionnaire for completion prior to the physician encounter. The completed
questionnaire can be scored by office staff, with positive responses followed up during
the examination.
NOTE: The form for the questionnaire is on page 1750, Spitzer et al (1994). The
copyright is held by Pfizer Inc, but can be photocopied as needed.
Instructions:
The questionnaire will help your doctor better understand problems that you may have.
Your doctor may ask you more questions about some of these items. Please make sure to
check a box for every item.
During the past month, have you often been bothered by:
(1) stomach pain
(2) back pain
(3) pain in your arms, legs or joints (knees, hips, etc.)
(4) menstrual pain or problems
(5) pain or problems during sexual intercourse
(6) headaches

(7) chest pain


(8) dizziness
(9) fainting spells
(10) feeling your heart pound or race
(11) shortness of breath
(12) constipation, loose bowels or diarrhea
(13) nausea, gas or indigestion
(14) feeling tired or having low energy
(15) trouble sleeping
(16) the thought that you have a serious, undiagnosed disease
(17) your eating being out of control
(18) little interest or pleasure in doing things
(19) feeling down, depressed or hopeless
(20) "nerves" or feeling anxious or on edge
(21) worrying about a lot of different things
During the past month:
(22) have you had an anxiety attack (suddenly feeling fear or panic)
(23) have you thought you should cut down on your drinking of alcohol
(24) has anyone complained about your drinking
(25) have you felt guilty or upset about your drinking
(26) was there ever a single day when you had 5 or more drinks of beer, wine, or liquor
Overall, would you say your health is:
excellent
very good
good
fair
poor
Responses:
26 questions: yes or no
overall health: one of the 5 options
Conditions screened for:
(1) somatoform disorders: 16 (questions 1-16)
(2) eating disorder: 1 (question 17)
(3) depression: 2 (questions 18-19)
(4) anxiety: 3 (questions 20-22)
(5) alcohol usage: 4 (questions 23-26)
References:
Katz RT, Tait RC. Chapter 13: Disability evaluation and unexplained pain. pages 257273 (268-269). IN: Rondinelli RD, Katz RT. Impairment Rating and Disability
Evaluation. WB Saunders Company. 2000.

Spitzer RL, Williams JBW, et al. Utility of a new procedure for diagnosing mental
disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994; 272: 17491756.
18.25.02 Screening for Mental Disorders in Medical Outpatients Using the
Predictors of Jackson et al
Overview:
Jackson et al developed a brief screening instrument for mental disorders in medical
outpatients. This can help identify patients who might benefit from a more extensive
evaluation for depressive or anxiety disorders .The authors are from the Uniform Services
University of the Health Sciences in Bethesda, Maryland.
Mental disorders identified in medical outpatients:
(1) depressive disorder or major depression
(2) anxiety disorder
(3) panic disorder
(4) somatoform disorder
(5) more than 1 of the above
Predictors:
(1) recent stress, in past week ("During the past week, have you been under stress?")
(2) number of physical symptoms: using the 15 physical symptoms from PRIME-MD
(see above)
(3) current health: responses as excellent, very good, good, fair or poor
Predictor
stress in past week
physical symptoms
current health

Finding
absent
present
<= 5
>= 6
excellent or very good
good, fair or poor

Points
0
1
0
1
0
1

where:
The abstract mentions 5 or more symptoms as a predictor, while the text refers to 6 or
more as the predictor (see Table 2, page 877; text on pages 877 and 878).
number of predictors =
= SUM(points for all 3 predictors)
Interpretation:
minimum number of predictors: 0
maximum number of predictors: 3
The more factors that a patient has, the greater the risk for a mental disorder.

The number of predictors present may help the primary care provider decide to perform
formal mental health screening in a patient.
Predictor
recent stress
physical symptoms
current health

Odds Ratio
6.7
4.0
2.2

number or risk factors


0
1
2
3

risk for mental disorder


2%
19%
39%
72%

95% Confidence Interval


3.3 13.6
2.1 7.9
1.1 4.3

References:
Jackson JL, Houston JS, et al. Clinical predictors of mental disorders among medical
outpatients. Arch Intern Med. 2001; 161: 875-879.
18.26 Tic Disorders
18.26.01 Clinical Features of Tourette Syndrome
Overview:
Tourette Syndrome (Gilles de la Tourette Syndrome) is lifelong movement disorder which
begins in childhood or adolescence. While a genetic condition (with the gene mapped to
chromosome 18q22.1) that often shows an autosomal dominant pattern of inheritance, it
is often classified as a psychological condition because of the associated behavioral issues.
A tic is defined as a sudden, rapid, recurrent, nonrhythmic, stereotyped movement or
vocalization (DSM-IV).
Clinical features:
(1) age of onset 2-18 years of age, with mean age of 7 years
(2) both involuntary muscular movements (motor tics) and uncontrollable noises (vocal
tics) present, although not necessarily at the same time
(3) tics tend to occur several times a day but may be intermittent. A tic-free period should
not last > 3 months.
(4) symptoms tend to vary over time, and may show exacerbation by anxiety or stress
(5) symptoms disappear during sleep
(6) lasts > 12 months and is usually a lifelong condition
(7) obsessive compulsive behavior and/or attention deficit hyperactivity disorder may be
present
(8) impairment in social, occupational or other areas of functioning
(9) other causes (stimulants, infection, metabolic conditions, etc.) excluded

Involuntary muscular movements include:


fast eye blinking
head jerking
facial grimacing
shrugging
knee jerks
groomng behaviors
jumping
Uncontrollable noises may include:
grunting
snoring sounds
sniffing
throat clearing
barking
"odd" sounds
echolalia (repetition of words spoken to the patient)
coprolalia (obscene words out of context) or profanity
References:
Frances A, First MB, Pincus HA. DSM-IV Guidebook. American Psychiatric Press, Inc.
Washington, DC. 1995. 307.23: Tourette's Disorder, page 398.
Nelson WE, Behrman RE, et al (editors). Nelson Textbook of Pediatrics, 15th Edition.
WB Saunders Company, 1996. Chapter 547: Movement disorders. pages 1709-1712
(547.4: Tics, page 1712).
Tourette Syndrome Assocation. Advertisement in: American Clinical Laboratory. 2001
(March): 54.
18.27 Activity-Related Addictive Behaviors
18.27.01 DSM-IV Criteria for Pathological Gambling
Overview:
The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) gives criteria for
the diagnosis of pathological gambling.
Criteria - both of the following:
(1) 5 or more behaviors (see below) indicating persistent and recurrent malaptive gambling
behavior
(2) The behavior is not better accounted for by manic episodes.
Behaviors:
(1) preoccupation with gambling (which may include reliving past gambling experiences,
planning the next venture, handicapping, or thinking of ways to get money with which
to gamble)

(2) needs to gamble with increasing amounts of money in order to achieve the desired
excitement
(3) has repeated unsuccessful efforts to control, cut back or stop gambling
(4) is restless and irritable when attempting to cut down or stop gambling
(5) gambles as a way of escaping from problems or of relieving a dysphoric mood (such as
helplessness, guilt, anxiety, depression)
(6) after losing money gambling, often returns another day to get even ("chasing" after
one's losses)
(7) lies to family members, therapist, or others to conceal the extent of involvement with
gambling
(8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance
gambling
(9) has jeopardized or lost a significant relationship, job, educational opportunity, or
career opportunity because of gambling
(10) relies on others to provide money to relieve a desperate financial situation caused by
gambling.
References:
Frances A, First MB, Pincus HA. DSM-IV Guidebook. American Psychiatric Press, Inc.
1995. 312.31 Pathological Gambling. pages 348-350.
Potenza MN, Kosten TR, Rounsaville BJ. Pathological gambling. JAMA. 2001; 286:
141-144.
18.27.02 Screening Population Groups at Increased Risk for Pathologic Gambling
Overview:
Certain groups of people show an increased risk of pathologic gambling. Screening for
pathologic gambling can be done effectively by the primary care provider who can then
attempt an intervention.
Groups at risk for pathologic gambling:
(1) persons with mental health problems (psychosis, anxiety or phobias, depression,
personality disorder, attention deficit, mood disorder, etc.)
(2) substance abusers
(3) males
(4) African Americans
(5) family history of pathologic gambling
Some would also include persons of lower socioeconomic status, However, the apparent
prevalence in the poor may reflect other issues (less able to mask behavior, consequence
of gambling losses, mental health problems, etc.)
References:
Potenza MN, Kosten TR, Rounsaville BJ. Pathological gambling. JAMA. 2001; 286:
141-144.