RATING SCALES USED IN SCHIZOPHRENIA

PRESENTER: DR.PAVITHRA C/P: DR. SAFEEKH. A. T

Introduction
A number of objective, quantitative rating scales are available to monitor clinical status in schizophrenia. Why the use of rating scales is important? 1. They provide a record that documents the patients response to treatment. This record is of particular value when the treatment is nonstandard (e.g,combination of antipsychotics) or expensive.

2. They can be compared with the patients, family members, and clinicians impressions of treatment effects and over time can clarify the longitudinal course of the patients illness. This can help temper excessive optimism when new treatments are begun and can provide useful information about the actual effects of prior treatments.

3. Use of anchored scales with criteria to assess the severity and frequency of symptoms helps patients become more informed self-observers. 4. Their use over time ensures that information about the same areas is collected at each administration and helps avoid omission of key elements of information needed to guide treatment.

NON SPECIFIC SCALES

Brief Psychiatric Rating Scale (BPRS, Overall and Gorham,1962) Comprehensive Psychopathology Rating Scale (CPRS, Asberg,1978) Krawiecka Manchester Scale (KMS Krawiecka, 1977) The Psychotic Symptom Rating Scales (PSYRATS, Haddock,1999) Nurses Observation Scale for Inpatient Evaluation (NOSIE, Honigfeld,1966)

Brief Psychiatric Rating Scale

BPRS developed to assess change in psychotic inpatients by Overall and Gorham 1962 18 items rated on a seven-point scale from 0 -not present to 6- most severe (1-7) Total score: 0 to 108 (18 to 126). use by experienced clinicians, time: 15-30 minutes Ratings include observations and patient reports of symptoms- can be used to rate patients with very severe impairment. Used as an outcome measure in treatment studies of schizophrenia; it functions as a measure of change and offers the advantage of comparability with earlier trials.

 Reliability : good to excellent , Validity: good Limits: overlap in some items. given its focus on psychosis & associated symptoms, only suitable for patients with fairly significant impairment. use in clinical practice is less supported as considerable training is required to achieve the necessary reliability. Strength: Brevity, Ease of administration, wide use, well researched status General applications:
evaluating baseline psychopathology clinical outcome treatment response

Items
Somatic concern Anxiety Emotional withdrawal Conceptual disorganization Guilt feelings Tension Mannerisms and posturing Grandiosity Depressive mood

Hostility Suspiciousness Hallucinatory behavior Motor retardation Uncooperativeness Unusual thought contents Blunted affect Excitement Disorientation

Comprehensive Psychopathology Rating Scale

CPRS Asberg et al 1978 Contains 67 items, including 1 global rating and, one item documenting the reliability of the interview 40 items - reported symptoms, 25- observed Graded from 0- no symptoms to 3- extreme scale Based on clinical interview Strengths: items sensitive to change clear description of items Limits: long time period of 45-60 mins Done by mental health clinicians measure changes in psychopathology over time

Krawiecka Manchester Scale

KMS Krawiecka et al 1977 / Krawiecka and Goldberg scale 8 items graded on 0- some evidence symptom is present to 4- severe symptom scale
Depression Anxious Flattened incongruous affect Psychomotor retardation Coherently expressed delusions Hallucinations Incoherence and irrelevance of speech Poverty of speech, mute

Based on standard clinical interview

 Both positive and negative symptoms assessed To evaluate change in clinical status for individuals with psychotic conditions Strengths:
Brevity clear guidelines for use ease of administration
lack of items that cover features of mania lack of sensitivity for severity rating of certain symptoms

Limits:

By clinicians or trained rater Time: 10-15 mins

The Psychotic Symptom Rating Scales

PSYRATS, Haddock, 1999 17-item semi-structured, clinician-administered scale consists of two subscales:
Auditory hallucinations-11 items, Delusions- 6 items.

evaluated on 5-point Likert scale- 0 to 4. Uses:

evaluate how specific interventions affect particular dimensions of psychotic symptoms change in symptoms as a result of treatment

Nurses Observation Scale for Inpatient Evaluation

NOSIE, G. Honigfeld and CJ Klett,1966 30 item scale Rated according to frequency of occurrence of 30 designated behaviors during previous 3 days (1- never to 5- always) Is quick, simple to administer, may be used to assess patients that may be too ill to participate in more interactive rating scales, including nonverbal individuals To assess behavior of patients on IP basis based on direct continuous observation. Time: 5- 10 mins Rated by IP nursing staff or trained rater

POSITIVE SYMPTOMS
Positive and Negative Syndrome Scale (PANSS, Kay et al, 1987) Scale for Assessment of Positive Symptoms (SAPS, Andreasen, 1981)

Positive and Negative Syndrome Scale

PANSS, SR Kay et al, 1987 Is a modification of older scales, BPRS. 30 items Each item is scored on a 7-point, item-specific Likert scale ranging from 1-absent to 7-extreme

Three subscales: seven items covering positive symptoms, range: 7- 49 seven covering negative symptoms, 7- 49 16 covering general psychopathology, Range: 16- 112 In recent years replaced by a finer division of five subscales based on factor analysis. Rating based on symptoms and functioning of the previous week

clinician rated semistructured interview guide available Time :30 to 40 minutes. Reliability: fairly high, with excellent internal consistency. Validity: good.

Applications assessing clinical outcome in treatment studies of schizophrenia and other psychotic disorders assessment of treatment response useful for tracking severity in clinical practice easy to administer reliably and sensitive to change with treatment. Used widely in research settings

Positive symptoms
P1-Delusions P2-Conceptual disorganization P3-Hallucinatory behavior P4-Excitement P5-Grandiosity P6-Suspiciousness/ persecution P7-Hostility

Negative symptoms
N1-Blunted affect N2-Emotional withdrawal N3-Poor rapport N4-Passive/Apathetic social withdrawal N5-Difficulty in abstract thinking N6-Lack of spontaneity and flow of conversation N7-Stereotyped thinking

General psychopathology
G1-Somatic concern G2-Anxiety G3-Guilt feelings G4-Tension G5-Mannerisms and posturing G6-Depression G7-Motor retardation G8-Uncooperativeness
G9-Unusual thought content G10-Disorientation G11-Poor orientation G12-Lack of judgment and insight G13-Disturbance of volition G14-Poor impulse control G15-Preoccupation G16-Active social avoidance

Scale for Assessment of Positive Symptoms

SAPS, Andreasen and Olsen 1981 34 item scale Utilized in conjunction with SANS Administered via general clinical interview + standardized questions + additional supporting information (staff)

Assesses 4 areas:
Hallucinations Delusions Bizarre behaviour Formal thought disorder

Score from 0- no abnormality to 5- severe total score ranges from 0 to 150 Clinician rated Time: 15- 20 mins

 Ratings from SANS and SAPS divided into 3 symptom dimension Psychoticism covers global ratings of hallucinations and delusions Negative covers affective flattening, alogia, avolition- apathy, anhedonia- asociality Disorganization covers bizarre behaviour, formal thought behaviuor, inappropiate affect.

To assess
baseline clinical status change overtime in patient in Schizophrenia patients in research

Good to excellent interrater reliability and validity is supported Longer and more difficult to learn to use than the PANSS and thus generally too detailed for use in clinical practice. Generally less utilized than SANS.

Hallucinations

Delusions

Bizarre behavior

Auditory Hallucinations
Voices commenting Voices conversing

Persecutory delusions
Delusions of Jealousy Delusions of guilt/ sin

Items

Positive formal thought behavior

Clothing and appearance

Social and sexual behavior Aggressive and agitated behavior

Derailment
Tangentiality Incoherence

Somatic/ tactile Hallucinations

Olfactory hallucinations Visual hallucinations Global rating of hallucinations

Grandiose delusions
Religious delusions Somatic delusions Delusions of reference Delusions of being controlled Delusions of mind reading

Repetitive or stereotyped behavior

Global rating of bizarre behavior

Illogicality
Circumstantiality Pressure of speech Distractible speech Clanging Global rating of positive FTD

Thought broadcasting
Thought insertion Thought withdrawal Global rating of delusions

NEGATIVE SYMPTOMS
Scale for Emotional Blunting (SEB, Abrams and Taylor,1978) Scale for Assessment of Negative Symptoms (SANS, Andreasen, 1981) Negative Symptom Scale- Lewine, Fogg and Meltzer (NSS-LFM, Lewine, Fogg and Meltzer,1983) Negative Symptom Scale- Pogue-Geile and Harrow (NSS-PGH, Pogue-Geile and Harrow,1984)

Negative Symptom Rating Scale (NSRS, Iager et al,1985) Bonn Scale for Assessment of Basic symptoms (BSABS, Gross et al,1987)

Positive and Negative Syndrome Scale (PANSS, Kay et al, 1987)

Schedule for Deficit Syndrome (SDS, Carpenter et al, 1988) Negative symptom Assessment Scale (NSAS, Alphs et al,1989)

Brief Negative Symptom Scale (BNSS, Kirkpatrick et al, 2010) Motor Affective Social Scale (MASS,Tremeau, 2008 ) Pearlson Scale (Pearlson,1984) Wing Scale (Wing,1961)

Self rated instruments: Subjective Experience of Deficit Scale (SEDS, Liddle and Barnes,1988) Subjective Deficit Syndrome Scale (SDSS, Petho and Bitter,1985)

Scale for Emotional Blunting

Abrams and Taylor,1978 Originally constructed to determine clinical descriptions of emotional blunting in schizophrenia Descriptive phrases are listed under 16 items: 4 affect, 4 thought content and 8 behavior Items scored on 3 point scale (0 absent, 2 clearly present) Includes three subscores:
lack of pleasure seeking behaviour, affective blunting, cognitive blunting.

Scale for Assessment for Negative Symptoms

SANS, N. Andreasen, 1981 To be used with SAPS Based on clinical interview, direct observation and additional information Done by clinicians or trained rater Time: 15-20 mins Uses: To assess negative symptoms To assess baseline clinical status and change overtime in individuals with schizophrenia

 25 item scale Evaluates five domains: alogia,affective blunting,avolition-apathy,anhedonia-asociality and attention Rated on 0- not present to 5- severe scale Individual items may be scored high for individuals with other types of mental illness such as depression or drug induced psychotic disorder Strengths: relative ease of administration and well researched reliability

Negative Symptom ScaleLewine, Fogg and Meltzer

Lewine, Fogg and Meltzer,1983 Incorporates items from: Nurses Observation Scale for Inpatient Evaluation, 30 item version (NOSIE-30, Honigfeld, 1966) : 8 items sits a lot, neat (-), does things (-), speaks (-), messy, sleeps a lot, is slow, clean (-) rated on a 3 point scale (absent, moderate, severe)

Schedule for Affective Disorders and Schizophrenia (SADS, Endicott and Spitzer, 1978): 11 items fatigue, loss of interest, loss of sexual interest, slowed speech, slowed body movements, depressed appearance, inappropriate affect, blunted affect, loose associations, poverty of content, incoherence rated on 2 point scale ( present/ absent)

Negative Symptom ScalePogue-Geile and Harrow

NSS-PGH, Pogue-Geile and Harrow,1984 Derived from Behavior Rating Schedule of the Psychiatric Assessment Interview (carpenter 1976) which is a modification of Present State Examination 8 ed by Carpenter and Strauss 1974 Individual items flat affect, poverty of speech, psychomotor retardation

Rated on 3 point scale (0-2)

Negative Symptom Rating Scale

NSRS, Iager et al,1985 Semi structured interview, 10 item, 7 point (0-6) Was made in an attempt to avoid redundancy found in other scales and make it short, concise, and precise It assess:
Thought process through speech and judgment- decision making Cognition through memory, attention and orientation Volition through, grooming, motivation and motion Affect and relatedness through emotional response and expressive relatedness.

 Patients rated on symptoms and behavior over time History from patient and if lacking from other sources Raters to assign highest score possible for a given item Time required: 10 mins

Bonn Scale for Assessment of Basic symptoms

BSABS, Gross et al,1987 assesses self-perceived basic symptoms, mental problems at the prepsychotic prodromal stage or close to psychosis onset. Consists of six subscales of Basic symptoms.
A + B, scales of dynamic deficits C, cognitive disturbances D, coenesthetic experiences E, central vegetative disturbances F, autoprotective behaviour

Schedule for Deficit Syndrome

SDS, Carpenter et al, 1988 Developed to assess presence or absence of deficit syndrome of schizophrenia Rates 6 negative symptoms:
Restricted affect Poverty of speech Diminished emotional range Diminished social drive Diminished sense of purpose Curbing of interests

Generates a global severity and global deficit score

 Attempts to distinguish between transitory negative symptoms (related to akinesia, dysphoria, recent psychosis, understimulating environment,chronic medications) and true chronic negative symptoms (deficit symptoms) Scale seeks to emphasize chronic deficit symptoms, time frame is crucial, and hence rater must be familiar with patients longitudinal course (periods of relapse and remission) before rating (sources).

 To qualify deficit syndrome patient must

meet DSM III R criteria for schizophrenia, have 2 of 6 or more deficit symptoms listed in the scale, have no indication that it is caused by depression, anxiety, drug effect, or environmental deprivation and have them for the preceding 12 months

It is not used to rate severity of negative symptoms.

Negative symptom Assessment Scale

NSAS, Alphs et al,1989 Designed to measure severity of negative symptoms Has 27 items and 1 global item Scored on 6 point scale (1- absent, 6 severe)

Semistructured interview, rated based on rater observation and what patient reports over previous week 6 categories of items :communication, affectemotion, social activity, interests, cognition, psychomotor activity

Brief Negative Symptom Scale

BNSS, Kirkpatrick et al, 2010 13-item instrument measures these 5 domains
blunted affect, alogia, asociality, anhedonia, and avolition.

interrater, test-retest, and internal consistency of the instrument were strong

Motor Affective Social Scale

Fabien Tremeau 2008 Consists of 8 items 5-minute structured interview measures hand co-verbal gestures, spontaneous smiles, voluntary smiling. recommended rating of specific behaviors that are defined as negative symptoms

Pearlson Scale
Pearlson 1984 6 item scale Used two items from KMS- poverty of speech and emotional flattening and added apathy, poor personal hygiene, absence of friends, and asexuality

Wing Scale
J K Wing 1961 To assess and classify patients with chronic schizophrenia. Not to measure change Purpose is to subclassify patients with chronic schizophrenia according to rating of 4 symptoms:
Flatness of affect Poverty of speech Incoherence of speech Coherently expressed delusions Global factor related to severity of illness

5 point scale (1-5) Assessment done with Semistructured interview First 10 mins to establish rapport by asking neutral questions and next 10- 20 mins specific questions

Subjective Experience of Deficit Scale

SEDS, Liddle and Barnes,1988 Consists 21 items in 6 groups:
Abnormal thinking and concentration Disturbance and affect Impaired will and decreased energy Disturbance of perception Intolerance of stress Disturbance of voluntary movement

Ratings based on patients descriptions of own behaviour and examples of how abnormal experiences interfere with daily activities

Subjective Deficit Syndrome Scale

SDSS, Petho and Bitter, 1985; Jaeger 1990 Based on experimental subscale of Subclinical Symptoms Scale of Petho and Bitter and was adapted and modified to American population (Bitter, 1989; Jaeger 1990)

Consists of 19 items that constitute subjective complains and is based on patients self report

CATATONIA
Bush-Francis Catatonia Rating Scale (BFCRS, Bush,1996) Bush Francis Catatonia Screening Instrument (Bush,1996) Braunig Catatonia Rating Scale (Braunig, 2000) Rogers catatonia scale ( Roger 1985) Modified Rogers scale (Mckenna ,1991) Northoff catatonia scale (Northoff ,1999) Modified 14 Lohr and Wisniewski scale (Lohr and Wisniewski, 1987)

BushFrancis Catatonia Rating Scale

Most widely used instrument for catatonia in research studies and case reports. Bush,1996 Has 23 items 0 - 3 scale to rate severity Shorter, 14-item screening version Presence or absence for screening. Reliability and validity is established >2 items caseness

Items
Excitement Immobility/stupor Mutism Staring Posturing/catalepsy Grimacing Echopraxia/echolalia Stereotypy Mannerisms Verbigeration Rigidity Negativism

Waxy Flexibility Withdrawal Impulsivity Automatic obedience Mitgehen Gegenhalten Ambitendency Grasp Reflex Perseveration Combativeness Autonomic abnormality

Braunig Catatonia Rating Scale

Braunig, 2000 21 items 16 motor, 5 behavioral Caseness presence of 4 symptoms

Rogers catatonia scale

Roger 1985 22 items use in: patients with depressive and other mood disorders to differentiate the depressed catatonics from non depressed parkinsons patients

Modified Rogers Scale

Mckenna ,1987 36 items grouped into 10 categories No cutoff for caseness

Rates abnormalities in movement, volition, speech and overall behaviour

Aids in the distinction of catatonic signs from seemingly similar extrapyramidal sideeffects

Northoff catatonia rating scale

Northoff 1999 40 items divided into motor, affective and behavioral categories Caseness defined as atleast 1 item in all categories

COGNITIVE SYMPTOMS
Specific scales: Schizophrenia Cognition Rating Scale (SCoRS, Keefe, 2006) Brief Assessment of Cognition in Schizophrenia (BACS, Keefe, 2006) Non specific: Executive Interview (EXIT) Direct Assessment of Functional Status- Revised edition (McDougall, 2010) Mini- Mental State Examination (MMSE, Folstein, 1975)

Schizophrenia Cognition Rating Scale

18-item interview-based assessment of cognitive deficits and the degree to which they affect day-to-day functioning. Interview of patient and an informant Assesses
1. 2. 3. 4. 5. 6. attention, memory, reasoning and problem solving, working memory, language production, motor skills

Rated on a 4-point scale. Higher ratings : impairment. Each item has anchor points for all levels of the 4-point scale. Are based on degree of impairment & degree to which the deficit impairs day-to-day functioning.

Brief Assessment of Cognition in Schizophrenia

Takes approximately 30- 35 minutes BACS includes brief assessments of
1. 2. 3. 4. 5. 6. reasoning and problem solving, verbal fluency, attention, verbal memory, working memory, motor speed.

easy to administer and score designed to measure treatment-related improvements; includes alternate forms. high test-retest reliability

THOUGHT
Scale for the Assessment of Thought, Language and Communication (TLC, Andreasen, 1986) Thought disorder index (TDI, Coleman, 1993) Thought and Language Index (TLI, Liddle, 2002)

Scale for the Assessment of Thought, Language and Communication

TLC, Andreasen, 1986 Subsets incorporated in SAPS & SANS contains 18 items including one global item score 30 minutes. By trained clinician

used to assess thought disorder with good reliability, particularly in research studies examining thought disorder or thought disturbances in schizophrenia. need for careful training and extensiveness of the measure, has limited use for clinical practice.

DEPRESSION
Specific scale: Calgary Depression Scale for Schizophrenia (CDSS, Addington, 1990) Non specific scales: Montgomery and Asberg Depression Rating Scale (MADRS, Montgomery & Asberg, 1978) Hamilton Rating Scale for Depression (HAM-D/ HRSD, Hamilton, 1960) Beck Depression Inventory (BDI, Beck, 1988) Zung Depression Scale ( SDS, Zung, 1965) Depression Outcomes Module ( DOM, Smith, 1995) Carroll Depression Scale (CDS-R/ CRS, Carroll, 1981) Raskin Depression Rating Scale (RDRS, Raskin, 1969)

Calgary Depression Scale for Schizophrenia

CDSS, Addington,1990 Nine-item scale semi-structured interview. (8-structured questions, and 1- observer rated.) specifically developed for assessment of severity of depression in patients with schizophrenia. Compared with the HAM-D, there is less overlap between positive and negative psychopathology. Items do not focus on weight change and initial insomnia, both of which can be confounded by the drug treatment of schizophrenia. rated on a four-point scale: 0=absent; 3=severe. 15 to 20 minutes.

SUICIDAL RISK
Specific: InterSePT Scale for Suicidal Thinking (ISST, Lindenmayer, 2003). Schizophrenia Suicide Risk Scale (SSRS, Taiminen, 2001)

Non- specific scales: Beck Scale for Suicide Ideation (BSS, Beck, 1979) California Risk Estimator for Suicide ( CRES, Motto, 1985) Beck Hopelessness Scale (BHS, Beck, 1974) Suicide Probability Scale (Cull & Gill, 1988)

InterSePT Scale for Suicidal Thinking

ISST, Lindenmayer, 2003 semi-structured 12 item instrument rated on three levels of increasing intensity (0, 1, or 2). derived from the Scale for Suicide Ideation, assessment of current suicidal ideation in patients who have schizophrenia and schizoaffective disorders 20 minutes by trained rater

Schizophrenia Suicide Risk Scale

SSRS, Taiminen, 2001 25-item semistructured tool for estimating short-term risk for suicide,
includes 13 History items assessing demographic and clinical variables derived from a psychological autopsy study of suicide in schizophrenia, items assessing clinical severity, and items derived from the Calgary Depression Scale

MANIA
Schedule for Affective Disorders and Schizophrenia (SADS Endicott and Spitzer 1978) Scale for Manic Symptoms Young Mania Rating Scale (YRMS, Young, 1978) Mania State Rating Scale (MSRS, Beigel, 1971) Bech- Rafaelsen Mania Scale ( BRMS, Bech & Rafaelsen, 1979)

Schedule for Affective Disorders and Schizophrenia

SADS Endicott and Spitzer 1978 Attempt to resolve dilemma b/w schizophrenia and mood disorder. Semi- structured interview with open ended question to make diagnosis using RDC Has 2 parts
Part I- symptoms are rated in 2 periods ( 1 week before interview, one week period during past yr when symptoms were worst the patient experienced) Part II- past and treatment history

Time: 60 mins Requires trained interviewer Used to diagnose major psychiatric disorders

GLOBAL RATING SCALES

Clinical Global Impression (CGI, Guy, 1976) Global Assessment of Functioning Scale (GAF, Endicott, 1976) Short Form 36-Item General Health Survey (SF-36; Ware & Sherbourne, 1992) Social and Occupational Functioning Scale (SOFAS, Saraswat, 2005) Social Behavioral Asssement Scale (Platt, 1983) Behavior and Symptom Identification Scale (BASIS32; Eisen, Dill, & Grob, 1994) COOP Charts for Adult Primary Care Practice (Nelson, 1987) Duke Health Profile (DUKE, Parkerson, 1990)

Clinical Global Impression

CGI, Guy, 1976 developed by NIMH 3 item scale measures overall illness severity and evaluate response to treatment in psychiatric patients Items: each rated separately severity of illness, rated 1- normal, 7- among the most severely ill global improvement, rated 1- very much improved, 7- very much worse therapeutic response rated as a combination of therapeutic effectiveness and adverse effects Useful where change over time is to be assessed. Usually paired with other scales, BPRS Clinician rated Time: 5 mins

Global Assessment of Functioning Scale

GAF, Endicott, 1976 Originated from Health Sickness Rating Scale (Luborsky, 1962) used as axis V in DSM IV. GAF is Axis V for DSM III R & IV 100 point single item scale with vales from 1 to 100 representing sickest person to healthiest. Divided into 10 equal parts with 81-90 & 91-100 exhibit superior functioning and most OP fall in 31- 70 and IP in 140 range Measures global functioning level of psychiatric patients Once evaluated by clinical professional assessment takes seconds.

Short Form 36-Item General Health Survey

SF-36; Ware & Sherbourne, 1993 Developed as a general measure of health status from the patient's point of view that would be independent of specific diseases

consists of 36 items, a mixture of yesno questions and short Likert scales. Focused on the individual's functional status as it relates to physical problems, pain, and emotional difficulties over the last 4 weeks.

 An acute version, focused on the past week, 8and 12-item versions also available. Uses: wide use in health services research and has special utility for comparing health outcomes across disparate diagnostic groups. used in clinical and health administration practice to track outcomes for individual patients or health systems

 Eight separate subscales:

physical function, physical role function, pain, general health, vitality, social function, emotional role function, and mental health.

self-report instrument but can easily be read by an interviewer . Time:10 to 15 minutes.

SIDE- EFFECTS
Abnormal Involuntary Movement Scale (AIMS, NIMH, 1976) Simpson Angus Scale (SAS, Simpson & Angus, 1970) Extrapyramidal Symptom Rating Scale (ESRS, Chouinard, 1980) Barnes Akathisia Rating Scale (BAS, Barnes, 1989)

Abnormal Involuntary Movement Scale

AIMS, NIMH, 1976 clinical examination and rating scale developed to measure dyskinetic symptoms in patients taking antipsychotic drugs. 12 items, rated on five-point 0 to 4 scale. changes in global severity and individual areas can be monitored over time.

Ten items movements in sections rating global severity and those related to specific body regions; two items concern dental factors that can complicate the diagnosis of dyskinesia.

 In the presence of extended neuroleptic exposure and the absence of other conditions causing dyskinesia, mild dyskinetic movements in two areas or moderate movements in one area tardive dyskinesia. Trained clinician raters, Time: 10 minutes. patients receiving long-term neuroleptic drugs clinical settings and research, both for monitoring patients for the development of tardive dyskinesia and for tracking changes in tardive dyskinesia over time.

QUALITY OF LIFE
Quality of Life Scale (QLS, Heinrichs, 1984) Lehman Quality of Life Interview (QOLI, Lehman, 1988) Quality of Well Being Scale (QWB, Bush, 1970) Sickness Impact Profile Modified (SIP, Bergner, 1976) Quality of Life Self- Assessment Inventory (QLS- 100) Psychological General Well Being Schedule (PGWB, Dupuy, 1970) Nottingham Health Profile (NHP, McKenna, 1990)

Quality of Life Scale

QLS, DW Heinrichs & WT Carpenter, 1984 21 item, Rated on 7 point scale Not pure QOL scale, also measures negative symptoms utilizing semistructured interview

Used in evaluation of different treatment in schz and assess their QOL

4 categories covers physical functioning, occupational role, interpersonal relationships and psychological functioning Trained clinical personnel 30- 45 mins

SOCIAL PERFORMANCE
Social Functioning Scale (SFS; Birchwood,1990) Multnomah Community Ability Scale (MCAS; Barker & Barron, 1997) Social Performance Schedule

SEXUAL FUNCTIONING
Arizona Sexual Experience Scale (ASES, MaGaheuy, 2000) five-item rating scale

Quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm.
Total score: 5 to 30, with the higher scores indicating more sexual dysfunction

AGRESSION
Buss- Durkee Hostility Inventory (BDHI, Buss & Durkee, 1957) Overt Agression Scale- Modified (OAS-M, Coccaro, 1991) State- Trait Anger Expression Inventory (STAXI-2, Spielberger, 1985)

PROGNOSIS
Chestnut lodge prognostic scale for chronic schizophrenia ( Fenton, 1987) simple and reliable, 5-item, 12-point prognostic scale for chronic schizophrenia independent of chronicity measures prognosis as the product of a dynamic interplay between the
highest level of adaptive occupational and social functioning ever achieved by the individual and invasiveness of the Axis I disorder as manifest by genetic loading (family history of schizophrenia), erosion of reality testing (psychotic assaultiveness), and preservation of affect in psychopathology (depressed mood).

INSIGHT
Insight and Treatment Attitudes Questionnaire (ITAQ, McEvoy, 1989)-11 items. Insight scale (IS,Markova & Berrios,1992)32 items. Scale to Assess Unawareness of Mental Disorder (SUMD, Amador,1993)- 6 general items, 4 subscales with 17 items each. Schedule for Assessment of Insight

 Insight scale (IS, Birchwood,1994)- 8 item scale. Three subscales: labeled awareness, relabel, and need for treatment. Beck cognitive insight scale (BCIS, Beck,2003)-15 items. Two subscales: selfreflectiveness and self-certainity. Insight item of the Present State Examination (PSE, Wing,1974)

EXPRESSED EMOTIONS
Screening instrument: five minute speech sample: (Magana,1986; Gottschalk,1989) Camberwell Family Interview: (CFI, Rutter & Brown, 1966) Level of Expressed Emotion scale: (LEE, Cole & Kazarian, 1988) Influential Relationship Questionnaire (IRQ, Baker et al, 1979) Perceived Criticism Scale (PCS, Hooley & Teasdale, 1989).

 Patient Rejection Scale (PRS, Kriesman, 1979) Family Environment Scale (FES, Moos & Moos, 1981) Questionnaire for Assessment of Expressed Emotion (QAE, Docherty,1990) Family Emotional Involvement & Criticism Scale (FEICS, Shield, 1992) Parental Attitude Questionnaires

Camberwell Family Interview

CFI, Rutter & Brown, 1966 semi-structured interview assesses the attitudes and feelings expressed by a key relative about the patient who has had a recent episode of psychosis Scales rated:
critical comments, hostility, emotional over- involvement, warmth, positive remarks

High EE: 6/> critical comments or 3/> EOI or demonstrates hostility towards the patient/relative

BURDEN
Burden Assessment Schedule (BAS, Sell, 1998) Family Burden Interview Scale Subjective Burden Scale Objective Burden Questionnaire

PRODROMAL STATE
Screening: PRODscreen Prodromal Questionnaire (PQ) Youth Psychosis At Risk Questionnaire (YPARQ) Structured Interview of Prodromal Syndromes- screen

Assessment: Comprehensive Assessment of At-Risk Mental States (CAARMS, Yung, 2005). Structured Interview of Prodromal Syndromes (SIPS, Miller, 2003) Bonn Scale for the Assessment of Basic Symptoms (BSABS) . Schizophrenia Prediction Instrument Adult version (SPI-A) Early Recognition Inventory (ERIraos, Hafner, 2004) Interview for the Retrospective Assessment of the onset of schizophrenia (IRAOS ,Hafner, 1992)

Comprehensive Assessment of At-Risk Mental States

CAARMS, Yung, 2005 Examines
perception disturbances, formal thought disorder and disorganization, abnormal thought content, motor difficulties, concentration and attention, emotion and affectiveness, energy and stress tolerance

semi-structured interview. It also assesses the severity, duration and frequency of these prodromal symptoms. One third of subjects fulfilling CAARMS criteria developed a psychosis within the next year.

NON- SPECIFIC DIAGNOSTIC SCALES

Present State Examination- Ninth Edition (PSE, Wing, 1974) Schedules for Clinical Assessment in Neuropsychiatry (SCAN, Wing, 1990) Diagnostic Interview Schedule (DIS, Robins, 1981) Structured Clinical Interview for Axis I DSM IV Disorders (SCID, First, 1995) Composite International Diagnostic Interview (CIDI, Kessler, 1998)