Catatonia Rating Scale
- Use the presence or absence of items 1 - 14 for screening.
- Use the 0 - 3 scale for items 1 -23 to rate severity.
1. Excitement:
Extreme hyperactivity, constant motor unrest which is apparently non-purposeful. Not to be attributed to akathisia or goal-directed agitation.
0 - Absent
I - Excessive motion, intermittent.
2 - Constant motion, hyperkinetic without rest periods.
3 - Full-blown catatonic excitement, endless frenzied motor activity.
2. Immobility/stupor:
Extreme hypoactivity, immobile, minimally responsive to stimuli.
0 - Absent.
1 - Sits abnormally still, may interact briefly.
2 - Virtually no interaction with external world.
3 - Stuporous, non-reactive to painful stimuli.
3. Mutism:
Verbally unresponsive or minimally responsive.
0 = Absent.
1 = Verbally unresponsive to majority of questions; incomprehensible whisper.
2 = Speaks less than 20 words/5mins.
3 = No speech.
4. = Staring:
Fixed gaze, little or no visual scanning of environment, decreased blinking.
0 = Absent.
1 = Poor eye contact, repeatedly gazes less than 20 s between shifting of attention; decreased blinking.
2 = Gaze held longer than 20 s, occasionally shifts attention.
3 = Fixed gaze, non-reactive.
5. Posturing/catalepsy:
Spontaneous maintenance of posture (s), including mundane (e.g. sitting or standing for long periods without reacting).
0 = Absent.
1 = Less than I mm.
2 Greater than one minute, less than 15 mm.
3 Bizarre posture, or mundane maintained more than 15 mm.
6. Grimacing:
Maintenance of odd facial expressions.
0 = Absent.
1 = Less than l0s.
2 = Less than 1 mm.
3 = Bizarre expression(s) or maintained more than 1 mm.
7. Echopraxia/echolalia:
Mimicking of examiner's movements/speech.
0 = Absent
1 = Occasional.
2 = Frequent.
3 = Constant
8. Stereotypy:
Repetitive, non-goal-directed motor activity (e.g. finger-play, repeatedly touching, patting or rubbing self); abnormality not inherent in act but in its frequency.
0 - Absent
1 - Occasional.
2 - Frequent.
3 - Constant.
9. Mannerisms:
Odd, purposeful movements (hopping or walking tiptoe, saluting passers-by or exaggerated caricatures of mundane movements); abnormality inherent in act itself.
0 - Absent
1 - Occasional.
2 - Frequent.
3 - Constant.
10. Verbigeration:
Repetition of phrases or sentences (like a scratched records).
0 - Absent.
1 - Occasional.
2 - Frequent, difficult to interrupt.
3 - Constant.
11. Rigidity:
Maintenance of a rigid position despite efforts to be moved, exclude if cog-wheeling or tremor present
0 = Absent.
I = Mild resistance.
2 = Moderate.
3 = Severe, cannot be repostured.
12. Negativism:
Apparently motiveless resistance to instructions or attempts to move/examine patients. Contrary behaviour, does exact opposite of instruction.
0 - Absent
I - Mild resistance and/or occasionally contrary.
2 - Moderate resistance and/or frequently contrary.
3 - Severe resistance and/or continually contrary.
13. Waxy flexibility:
During reposturing of patient, patient offers initial resistance before allowing himself to be repositioned, similar to that of a bending candle.
0 - Absent
3 - Present.
14. Withdrawal:
Refusal to eat, drink and/or make eye contact.
0 = Absent.
1 = Minimal P0 intake/interaction for less than 1 day.
2 = Minimal P0 intake/interaction for more than 1 day.
3 = No P0 intake/interaction for 1 day or more.
15. Impulsivity:
Patient suddenly engages in inappropriate behaviour (e.g. runs down hallway, starts screaming or takes off clothes) without provocation. Afterwards can give no, or only a facile explanation.
0 - Absent.
1 - Occasional.
2 - Frequent.
3 - Constant or not redirectable.
16. Automatic obedience:
Exaggerated cooperation with examiner's request or spontaneous continuation of movement requested.
0 = Absent.
1 = Occasional
2 = Frequent
3 = Constant.
17. Mitgehen.
"Anglepoise lamp" arm raising in response to light pressure of finger, despite instructions to the contrary.
0 = Absent.
3 = Present.
18. Gegenhalten:
Resistance to passive movement which is proportion to strength of the stimulus, appears automatic rather than willful.
0 - Absent
3 - Present.
19. Ambitendency:
Patient appears "motorically stuck" in indecisive, hesitant movement.
0 - Absent.
3 = Present.
20. Grasp reflex:
Per neurological exam.
0 = Absent
3 = Present
21. Perseveration:
Repeatedly returns to same topic or persists with movement
0 = Absent.
3 = Present.
22. Combativeness:
Usually in an undirected manner, with no, or only a facile explanation afterwards
0 = Absent
1 = Occasionally strikes out, low potential for injury.
2 = Frequently strikes out, moderate potential for injury.
3 = Serious danger to others.
23. Autonomic abnormality:
Circle: temperature, BP, pulse, respiratory rate, diaphoresis.
0 = Absent
1 = Abnormality of one parameter (exclude pre-existing hypertension).
2 = Abnormality of two parameters.
3 = Abnormality of three or more parameters.
Appendix I Standardized examination for catatonia
The method described here is used to complete the 23-item Bush-Francis Catatonia Rating Scale (CRS) and the 14-item Catatonia Screening Instrument (CSI). Item definitions on the two scales are the same. The CRS measures the severity of 23 signs on a 0- 3 scale, while the CSI measures only the presence or absence of the first 14 signs.
Ratings are to be made solely on the basis of observed behaviour during the examination with the exception of completion of the items for 'withdrawal' and autonomic abnormality', which may be based on directly observed behaviour and for chart documentation.
As a general rule, only rate items which are clearly present If uncertain as to the presence of an item, rate the item as '0'.
| Procedure | Examines | |
| 1 | Observe patient while trying to engage in a conversation | Activity level Abnormal movements Abnormal speech. |
| 2 | Examiner scratches head in exaggerated manner | Echopraxia |
| 3 | Examine arm for cogwheeling. Attempt to reposture, instructing patient to "keep your arm loose" - move arm with alternating lighter and heavier force. | Negativism Waxy flexibility Gegenhalten |
| 4 | Ask patient to extend arm. Place one finger beneath hand and try to raise slowly after stating, "Do NOT let me raise your arm". | Mitgehen |
| 5 | Extend hand stating "Do NOT shake my hand". | Ambitendence |
| 6 | Reach into pocket and state,"Stick out your tongue, I want to stick a pin in it". | Automatic obedience |
| 7 | Check for grasp reflex. | Grasp reflex |
| 8 | Check chart for reports of previous 24-hour period. In particular check for oral intake, vital signs, and any incidents. | |
| 9 | Attempt to observe patient indirectly, at least for a brief period, each day. |
Fink, 1996, c/o David Healy