Escolar Documentos
Profissional Documentos
Cultura Documentos
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]
(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]
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
general health
vitality
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
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
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
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
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
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
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
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
1
2
3
4
5
6
7
8
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
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
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
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.
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
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
Points
0
1
2
3
Points
3
2
1
0
Points
0
1
2
3
Points
3
2
1
0
Points
3
2
1
0
Points
3
2
1
0
Points
3
2
1
Points
3
2
1
0
no, 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?
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
0
1
2
3
0
0
1
2
3
0
0
1
2
3
0
0
1
2
3
0
0
1
2
3
0
0
1
2
3
0
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:
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
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
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
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
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
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
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
0
0
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?
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
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
Response
most of the time
Points
3 [A]
I feel cheerful
2
1
0
0 [D]
1
2
3
3 [A]
2
1
0
0 [D]
1
2
3
3 [A]
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]
1
0
3 [A]
quite a lot
not very much
not at all
as much as ever I did
2
1
0
0 [D]
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
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
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.
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
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
Points if
Spontaneous
Points if with
Activation
none
minimal
mild
moderate
severe
0
1
2
3
4
0
0
1
2
3
Points
0
1
2
3
4
Points
0
1
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
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.
not at all
0
0
0
0
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
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
not at all
or very
slightly
0
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
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
2
2
2
2
2
2
2
3
3
3
3
3
3
3
very
much
4
4
4
4
4
4
4
not at all
or very
slightly
0
0
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
3
4
5
6
7
9
10
11
12
15
16
17
20
21
24
25
26
27
very
much
28
29
40
41
51
56
59
Response
not at all
just a little
pretty much
Points
0
1
2
My mind wanders.
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
Score
0
1
2
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
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
"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
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
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
3
4
Response
yes
no
yes
Points
0
2
0
no
yes
2
5
no
yes
0
2
no
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
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?
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
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.
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
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.
Finding
<= 5 minutes
Points
3
6 30 minutes
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
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.
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:
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
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
2
4
6
6
8
0
6
8
0
2
3
0
2
4
6
8
0
8
0
1
2
3
insight
4
0
1
2
3
4
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
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
1
2
3
4
2
3
1
2
aggressiveness
orientation
elevated mood
5
1
2
3
5
1
2
3
1
Global Ratings
Parameter
Finding
Points
manic state
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
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
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
suicide note
deception or concealment
of contemplated suicide
1
2
0
1
2
0
partial
complete
none
started but not completed; only thought
about
completed
none
1
2
0
1
1
2
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
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
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
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:
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:
(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
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
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
(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.