Title: BFCRS
Tags: BFCRS::Differences BFCRS::Items BFCRS::Terminology
On every note of this deck, unless a note says otherwise:
Score 0: Absent
Reference: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)
Wortzel, J. Bush-Francis Catatonia Rating Scale Assessment Resources University of Rochester Medical Center
Reference: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Item: Excitement
Identify: Observe
Description: excessive, frank motor activity typically involving the entire body
extreme hyperactivity, constant motor unrest, apparently non-purposeful
spontaneous w/o prompting, not elicited
exclude akathisia or goal-directed aggression
Example: walking around, pacing
inability to sit still; squirming in chair
constant or near-constant movement in bed; tossing and turning
Score 1: Excessive motion, intermittent
Score 2: Constant motion, hyperkinetic without rest periods
Score 3: Full-blown catatonic excitement, endless frenzied motor activity
Video: Excitement | Bush-Francis Catatonia Rating Scale Videos

Item: Immobility / Stupor
Identify: Observe + Elicit (on exam to confirm)
Description: reduced overall spontaneous physical activity and interactivity w/ external world
amount of movement is less than expected for context
stimuli is both social (others) and environmental (painful, aversive)
elicit for confirmation by administering a painful stimulus
Example: lying in bed motionless despite environmental stimuli
moving extremely slowly, as if through viscous substance
administering a painful stimulus for confirmation
Score 1: Sits abnormally still, may interact briefly
Score 2: Virtually no interaction with external world
Score 3: Stuporous (psychological), non-reactive to painful stimuli
Video: Immobility / Stupor | Bush-Francis Catatonia Rating Scale Videos

Item: Mutism
Identify: Observe + Elicit (verbally to confirm)
Description: Reduction in quantity of speech, number of spoken words
if aphasia is present, do not score item
Example: Nonverbal
Incomprehensible whispers
Sluggish speech, often w/ prolonged speech latency
Score 1: Verbally unresponsive to majority of questions; incomprehensible whisper
Score 2: Speaks < 20 words in 5 minutes
Score 3: No speech
Video: Mutism | Bush-Francis Catatonia Rating Scale Videos

Item: Staring
Identify: Observe
Description: Lack of appropriate visual interest or scanning of environment
Reduced visual pursuit of stimuli presented to patient
Example: Looking vacantly ahead
Maintaining straight-ahead gaze even while being turned
Score 1: < 20 sec b/w shifting of attention, poor eye contact, repeated gaze, decreased blinking
Score 2: > 20 sec gaze held, occasionally shifts attention
Score 3: Fixed gaze, non-reactive
Video: Staring | Bush-Francis Catatonia Rating Scale Videos

Item: Posturing / Catalepsy
Identify: Observe (posturing) or Elicit (catalepsy)
Description: Patient spontaneously assumes position or Patient able to be repositioned and then maintain
Maintenance of physical position against gravity for no apparent reason
Grade severity based on duration of finding
In milder forms, patient assumes position and their body slowly slumps back with gravity
Example: Arms held in contorted position over head
Truncal hunching over or bent back (i.e., opisthotonus, arc de cercle)
Hands held in front of body against gravity; forearms bent vertically in bed
"Psychological pillow", lying in bed w/ elevated head and neck as if invisible pillow underneath
Score 1: < 1 minute
Score 2: > 1 minute, < 15 minutes
Score 3: Bizarre posture, or mundane maintained > 15 min
Video: Posturing / Catalepsy | Bush-Francis Catatonia Rating Scale Videos

Item: Grimacing
Identify: Observe
Description: Facial muscles posturing (fixed motor contortions), facial muscles stereotypies (e.g., repetitive wincing, furrowing of brow),
or facial muscles mannerisms (e.g., exaggerated blinking or eye opening).
Single feature may be maintained (e.g., scrunched nose), or a series of sequential expressions of movements may alternate
Example: Scrunched nose (i.e., schnauzkrampf)
Repetitive wincing or furrowed brow
Exaggerated blinking or eye opening
Score 1: < 10 sec
Score 2: < 1 min
Score 3: Bizarre expression(s) maintained > 1 min
Video: Grimacing | Bush-Francis Catatonia Rating Scale Videos

Item: Echopraxia / Echolalia
Identify: Elicit (physically, verbally) + Observe (environment)
Description: Copying examiner's physical movements or speech
Mimicry is spontaneous, purposeless, appears automatic
Copying can be partial or intermittent
Patient may also copy persons on TV or others in room
Example: Scratching one's own head, patient repeats gesture
Series of distinctive hand gestures performed by someone on television, patient repeats
Patting one's own leg, patient pats their leg similarly
Standing and turning in a circle after watching another patient do the same action
Score 1: Occasional
Score 2: Frequent
Score 3: Constant
Video: Echopraxia / Echolalia | Bush-Francis Catatonia Rating Scale Videos

Item: Stereotypy
Identify: Observe
Description: Patient performs a normal activity repeatedly
Purposeless, abnormal in frequency, not abnormal itself
Score only behaviors, not speech (i.e., verbigeration)
Example: Finger-play
Repeatedly touching, patting or rubbing one's shirt, chin, leg, etc.
Rocking while sitting or standing
Score 1: Occasional
Score 2: Frequent
Score 3: Constant
Video: Stereotypy | Bush-Francis Catatonia Rating Scale Videos

Item: Mannerisms
Identify: Observe
Description: Spontaneous occurrence, where quality of movement or activity is abnormal in context and idiosyncratic to patient
Involves only a part of the body, especially those used to amplify or used as adjuncts to communication (e.g., hands, face)
Speech includes abnormal inflections, accents, prosody, tone, etc. (e.g., odd accent)
Behaviors (e.g., odd walk)
Example: Tip-toeing or hopping down a hallway
Exaggerated or affected gesticulations when talking
Speaking without reason in a robotic, sing-song, or accented voice
Score 1: Occasional
Score 2: Frequent
Score 3: Constant
Video: Mannerisms | Bush-Francis Catatonia Rating Scale Videos

Item: Verbigeration
Identify: Observe
Description: Spontaneous, purposeless repetition of phrases or sentences, as if listening to a record w/ a scratch that repeats a loop
Example: any phrase repeated several times, often in quick succession
Stereotypy of speech
Score 1: Occasional
Score 2: Frequent, difficult to interrupt
Score 3: Constant
Video: Verbigeration | Bush-Francis Catatonia Rating Scale Videos

Item: Rigidity
Identify: Elicit (on exam)
Description: Increased motor tone throughout the arc of movement
Clinician usually asks "keep your arm relaxed" before attempting to move their arm w/ alternating lighter and heavier force.
May be diffuse, or specific to body part (e.g., legs, arms, neck, trunk)
May be unidirectional (e.g., only on passive flexion, not extension)
Score based on most severe muscle group; note the muscle group
Known tremor or cogwheeling should not be scored
Example: Attempts to move patient's arm or leg yields marked stiffness
Upon assisting patient to sit up or turn to side, trunk remains stiff
Score 1: Mild resistance
Score 2: Moderate resistance
Score 3: Severe resistance, cannot be repostured
Video: Rigidity | Bush-Francis Catatonia Rating Scale Videos

Item: Negativism
Identify: Elicit
Description: Active opposition to a specific instruction regarding movement, or attempts to move/examine
When patient does exact opposite of what's being instructed (e.g., looks up when asked to look down; tenses when told to relax)
Unifying theme is behavioral response directly opposes the examiner
Response is elicited, active, without obvious motive
Example: Patient forcibly shuts eyes when attempting to open them
Actively resist attempts to roll them over in bed
Refuses simple actions (e.g., stick out tongue), but is able to do so; may be accompanied by oppositional, reflexive comments "no, I won't"
Patient lowers arm when asked to raise it
Behavior contrary to norms; pulling a door marked "push" or lying sideways in bed
Score 1: Mild resistance, occasionally contrary
Score 2: Moderate resistance, frequently contrary
Score 3: Severe resistance, continually contrary
Video: Negativism | Bush-Francis Catatonia Rating Scale Videos

Item: Waxy Flexibility
Identify: Elicit (on exam)
Description: Initial resistance / stiffness when examiner assesses muscle tone,
but then patient releases limb and reduces tone allowing movement
Example: Attempts to reposition patient, initially resists by maintaining prior posture, but after a couple seconds allows repositioning
Score 3: Present
Video: Waxy Flexibility | Bush-Francis Catatonia Rating Scale Videos

Item: Withdrawal
Identify: Observe + Elicit (give food to confirm)
Description: Absence of oral intake and eye contact
Corollaries in severe depression or failure to thrive
Requires collateral reports of patient's intake over ≥ 24 hours before exam
May be tested by placing food / drink in front of patient; score as zero if they eat / drink it when offered
Example: Looks at floor during evaluation, eyes dart away from examiner's when attempting to make eye contact
When patient refuses oral intake for extended time period, even when food is offered
Score 1: Minimal PO intake/interaction < 1 day
Score 2: Minimal PO intake/interaction > 1 day
Score 3: No PO intake/interaction for ≥ 1 day
Video: Withdrawal | Bush-Francis Catatonia Rating Scale Videos

Item: Impulsivity
Identify: Observe
Description: Sudden, inappropriate (for context), lacking clear rationale
Occurs automatically, w/o apparent forethought
Grades (0–3) indicate number of discrete actions; constant action is rare, like "flight of ideas" for behaviors
Example: Patient seated in conversation, suddenly stands up and begins drumming the windowsill
Lying still in bed, suddenly darts up, screams, bounces, lies back down as if nothing happened
Patient removes clothes for no reason during interview
Score 1: Occasional
Score 2: Frequent
Score 3: Constant
Video: Impulsivity | Bush-Francis Catatonia Rating Scale Videos

Item: Automatic Obedience
Identify: Elicit (verbally)
Description: Patient obeys instructions w/o apparent thought, as though instruction is a command that must be obeyed
Often obey suddenly, even to painful stimulus
Constancy means patient obeys last command w/o stopping, until new command to stop
Seen in Speech-Prompt Catatonia
Example: Extends hand to patient, responds reflexively to shake hand, even if otherwise immobile
Obeys series of commands reflexively
"I need to stick a pin in your tongue; go ahead and stick your tongue out"
Score 1: Occasional
Score 2: Frequent
Score 3: Constant
Video: Automatic Obedience | Bush-Francis Catatonia Rating Scale Videos

Item: Mitgehen
Identify: Elicit (on exam)
Description: "Do no let me lift your arm", then place light pressure w/ finger under arm/hand
Positive if arm rises easily, like anglepoise lamp
Occasional light-pressure under arm will cause it to lift all the way up suddenly as though yanked by invisible force
(discrete finding)
Score 3: Present
Video: Mitgehen | Bush-Francis Catatonia Rating Scale Videos

Item: Gegenhalten
Identify: Elicit (on exam)
Description: Increased muscle tone in an extremity (arm) when tension against passive movement is proportion to the force applied
Paratonic rigidity, "counter hold"
Resistance in patient's limb is reflexive, rather than behavioral as in negativism
(discrete finding)
Score 3: Present
Video: Gegenhalten | Bush-Francis Catatonia Rating Scale Videos

Item: Ambitendency
Identify: Observe + Elicit (on exam to confirm)
Description: Patient appears to be midway, hesitant, ambivalent to particular action
Stuck at the point of initiation (e.g., beginning to pick up a fork when food placed before them)
Stuck in midst of action (e.g., fork between plate and their mouth)
Vacillating by moving back and forth as though uncertain (e.g., seated person starting to stand, sitting back down, repeating)
Example: Extend hand to patient and say "Do not shake my hand"; getting stuck sticking out hand partway, or stuck w/ hand extended
Unable to pass through a doorway, taking half-step in and out repeatedly; may stop halfway in and out of doorway
"Stuck" when trying to feed self, put on glasses or socks
Score 3: Present
Video: Ambitendency | Bush-Francis Catatonia Rating Scale Videos

Item: Grasp Reflex
Identify: Elicit (on exam)
Description: Firmly stroke palmar surface of patient's hand from ulnar to radial palm
Reflexive hand closing, sometimes so tight their arm follows when examiner attempts to remove their fingers
(discrete finding)
Score 3: Present
Video: Grasp Reflex | Bush-Francis Catatonia Rating Scale Videos

Item: Perseveration
Identify: Observe + Elicit (verbally or on exam to confirm)
Description: Motor continuation of action, may have begun spontaneously or induced by interaction w/ examiner (e.g., handshake)
Verbal persistence in talking about the same idea or theme, unable to change topics
Verbal is common in delirium, dementia
Verbal inattention, inability to shift attention
Example: Patient provides their name to several questions in a row, continues talking about specific topic (e.g., something in the room, piece of clothing, etc.)
After a handshake, continues hand-shaking movement in air even after examiner's hand has been let go
Score 3: Present
Video: Perseveration | Bush-Francis Catatonia Rating Scale Videos

Item: Combativeness
Identify: Observe
Description: Aggression toward others done in an undirected manner (i.e., no clear targeted individual; victim is incidental to act itself)
Occurs sporadically and is not continuous
(discrete finding)
Score 1: Occasionally strikes out, low potential for injury
Score 2: Frequently strikes out, moderate potential for injury
Score 3: Serious danger to others
Video: Combativeness | Bush-Francis Catatonia Rating Scale Videos

Item: Autonomic Abnormality
Identify: Elicit (on exam) + Chart Review
Description: Vitals assessed during time of evaluation, or most recent vitals assessed, ideally w/in 1 hour since last catatonia assessment
Abnormalities may be too high or low in temperature, blood pressure, pulse, respiratory rate
Exclude elevated blood pressure if consistent w/ known hypertension uncontrolled at baseline
Do not exclude when acutely ill, may represent features of malignant catatonia
(discrete finding)
Score 1: Abnormality of 1 parameter (exclude pre-existing hypertension)
Score 2: Abnormality of 2 parameters
Score 3: Abnormality of 3 or greater parameters
Video: Autonomic Abnormality | Bush-Francis Catatonia Rating Scale Videos

Difference: Akathisia is internal "drive to move", motoric restlessness, typically of lower > upper extremities
Patients commonly aware of internal "drive", able to articulate this
Do not score Excitement where motoric activity is consistent w/ known akathisia
Item: Excitement
From Item: Akathisia

Difference: Immobility does not imply Staring, may present w/ several types of gaze:
blank stare, roving eyes, tracking environmental stimuli, forcibly closed, etc.
Staring refers to predominantly fixed gaze, straight ahead or blankly fixed on an object
Item: Immobility / Stupor
From Item: Staring

Difference: Immobility is diminished activity of entire body
Posturing / Catalepsy occurs in a single body part (e.g., arms, legs), often w/ preserved movement in other body parts
e.g., a patient may walk but hold arm up w/ Posturing / Catalepsy
Posturing / Catalepsy involves muscle tone that resists gravity, to keep body part in certain positions
Immobility may occur in a person lying in bed w/ normal muscle tone.
Immobility and Posturing / Catalepsy often co-occur
Item: Immobility / Stupor
From Item: Posturing / Catalepsy

Difference: Immobility is global behavior;
a person may move minimally but have flaccid tone when examined
Rigidity is increased muscle tone;
a person w/ mild rigidity may move spontaneously and normally
Item: Immobility / Stupor
From Item: Rigidity

Difference: Immobility is observed, spontaneous reduction in overall interaction w/ environment
Negativism is elicited, active opposition or resistance to examiner (e.g., resisting attempts to open eyes, mouth), doing opposite of what is being asked
Item: Immobility / Stupor
From Item: Negativism

Difference: Immobility is overall motor activity;
a person may have preserved oral intake when meals are provided and make eye contact
Withdrawal is specific absence of oral intake or eye contact;
a person may move spontaneously,
though common to present w/ reduced speed / degree of movement
Item: Immobility / Stupor
From Item: Withdrawal

Difference: Mutism is verbal non-response to questions
Negativism is resistance to instructions w/ motoric or behavioral response or physical attempts to move patient
Generally, failure to stop performing another catatonic feature (i.e., mutism) on command should not be scored as negativism
Item: Mutism
From Item: Negativism

Difference: Mutisim is absence or reduction of speech
Withdrawal concerns only oral intake and eye contact
Item: Mutism
From Item: Withdrawal

Difference: Whispering (voiceless phonation) that is incomprehensible scores 1 point for Mutism
Fluent, comprehensible whispering should be scores as Manneristic Speech
Comprehensible whispering in a patient who speaks < 20 words in 5 minutes is both Mutism and Mannerism
Item: Mutism
From Item: Manneristic Speech

Difference: Speech-Prompt Catatonia is a rare subtype, patient provides verbal responses (word, phrase) to questions but is otherwise mute
Score as automatic obedience; patient offering reflexive speech in response to examiner's questions
Item: Mutism
From Item: Speech-Prompt Catatonia

Difference: Staring may be looking straight ahead, at provider, vacant
Withdrawal is persistent lack of eye contact (e.g., as though dejected, actively avoiding eye contact)
Item: Staring
From Item: Withdrawal

Difference: Posturing / Catalepsy is maintaining body position, usually limbs, in space
Rigidity is muscle tone identified on physical examination
Catalepsy commonly exhibits degree of increased tone (Rigidity or Waxy Flexibility); score both
Item: Posturing / Catalepsy
From Item: Rigidity

Difference: Posturing / Catalepsy is maintaining body position, usually limbs, in space
Waxy Flexibility is increased muscle tone at the beginning of passive range of motion, diminishes once movement begins (i.e., like bending wax as it warms)
Catalepsy commonly exhibits Waxy Flexibility; score both
Item: Posturing / Catalepsy
From Item: Waxy Flexibility

Difference: Grimacing is only feature referring to abnormal movements of facial muscles
Posturing / Catalepsy, Stereotypy, Mannerisms are scored only where non-facial muscles are involved
Item: Grimacing
From Item: Posturing / Catalepsy, Stereotypy, Mannerisms

Difference: Echopraxia / Echolalia copying is spontaneous w/o asking
Automatic Obedience clinician asks patient to perform an action,
provides social indication eliciting action (e.g., extend hand to elicit handshake)
Item: Echopraxia / Echolalia
From Item: Automatic Obedience

Difference: Stereotypies restricted to one body part (e.g., movements of trunk, arms, hands)
Excitement involves most/entire body
Item: Stereotypy
From Item: Excitement

Difference: Stereotypy should be restricted to behaviors
Verbigeration is repeated stereotyped phrases in quick succession
Item: Stereotypy
From Item: Verbigeration

Difference: Stereotypy is repeated multiple times and performed spontaneously (i.e., not induced)
Motor Perseveration is rare, induced (e.g., letting go after shaking hand, continues to make shaking motion)
Item: Stereotypy
From Item: Motor Perseveration

Difference: Stereotypies are spontaneous
Speech-Prompt Catatonia is elicited, should be scored as automatic obedience
Item: Stereotypy
From Item: Speech-Prompt Catatonia

Difference: Behavioral Mannerisms are restricted to one body part (e.g., hands)
Excitement involves most or whole body
Item: Mannerisms
From Item: Excitement

Difference: Mannerisms are variants of abnormal behaviors;
mannerisms are odd every time they are performed in context
Stereotypies are normal behaviors repeated an abnormal number of times;
stereotypies would be unremarkable if they were done in isolation
Item: Mannerisms
From Item: Stereotypy

Difference: Manneristic speech is abnormally delivered
(e.g., robotic, sing-songy inflections, unusual accents)
Verbigeration describes repetition of stereotyped phrases
Item: Mannerisms
From Item: Verbigeration

Difference: Verbigeration is repetition of exact phrases or sentences
Verbal perseveration is common in dementia and delirium, considered evidence of inability to shift attention (i.e., form of inattention)
Item: Verbigeration
From Item: Verbal Perseveration

Difference: Rigidity is exclusively an increase in muscular tone assessed by passive movement on physical examination
Negativism is a behavior of opposition to instruction, or doing the opposite of instruction
Both may be present
Item: Rigidity
From Item: Negativism

Difference: Rigidity is exclusively an increase in muscular tone through the arc of movement assessed;
scored from 0 to 3
Waxy Flexibility is initial resistance that gives way w/ continued pressure,
as though a wax candle is being bent and becomes increasingly malleable as it warms;
is either present or absent
Item: Rigidity
From Item: Waxy Flexibility

Difference: Rigidity is exclusively an increase in muscular tone through the arc of movement
Gegenhalten is a specific increase in tone where the opposing force is proportional to the force applied by the examiner
Different limbs may exhibit different findings in tone;
if Gegenhalten is present in any limb, it should be scored
Item: Rigidity
From Item: Gegenhalten (paratonic rigidity)

Difference: If examiner instructs patient to stop a catatonic feature, it should not be scored as negativism
Negativism should be scored only when clearly present independent of other findings
Do not score Negativism when telling patient that is:
Excited to sit still,
Immobile to sit up in bed,
Staring to follow fingers w/ eyes,
Posturing / Cataleptic to put down arms,
Grimacing to relax face,
Echopraxic / Echolalic to stop copying what is said,
Stereotypic to stop moving arms,
w/ Manneristic Speech to speak normally,
w/ Verbigeration to stop repeating that phrase,
w/ Withdrawal to eat their food
Mitgehen is doing the opposite of instruction, should not be scored as negativism
Item: Negativism
From Item: Clinician tells to stop feature of catatonia

Difference: Negativism is opposition to motor command,
doing the opposite of instruction
Staring is an observational finding w/ confirmation by elicitation
(e.g., patient's gaze remains fixed ahead even when being rolled over in bed)
Item: Negativism
From Item: Staring

Difference: Negativism describes behavior
Rigidity, Gegenhalten, Waxy Flexibility describes muscle tone
Item: Negativism
From Item: Rigidity, Gegenhalten, Waxy Flexibility

Difference: Waxy Flexibility found at beginning of passive range of motion
Gegenhalten tone is proportional to force applied and often prevents full passive range of motion
Item: Waxy Flexibility
From Item: Gegenhalten

Difference: Impulsivity is sudden and inappropriate behaviors; defined by discrete bursts of behavior
Excitement is excessive duration or frequency of activity; constant
Constant Impulsivity (3/3) and Excitement (3/3) may co-occur (e.g., performing serial activities, jumping on bed, running in circles, flicking lights)
Item: Impulsivity
From Item: Excitement

Difference: Mitgehen is discrete, involves doing the opposite of instructions "don't let me move your...", but should not be scored as negativism
Negativism is elicited, active opposition or resistance to examiner (e.g., resisting attempts to open eyes or mouth)
Item: Mitgehen
From Item: Negativism

Difference: Gegenhalten is muscle tone proportional to applied force, often in one muscle group
(e.g., elicited on passive forearm extension);
not typically eliminated by distraction techniques
Negativism is oppositional behavior;
can be inconsistent, intermittent, vary w/ body region / muscle group
Item: Gegenhalten
From Item: Negativism

Difference: Ambitendency is when struck in midst of performing an action;
partial attempts to feed oneself may be initiated but halted midway
Withdrawal is a specific lack of oral intake, characterized by absence of attempts to feed oneself
Item: Ambitendency
From Item: Withdrawal

Difference: Motor Perseveration involves one body part
Excitement involves most or the entire body
Item: Motor Perseveration
From Item: Excitement

Difference: Verbal Perseveration is returning the same idea or topic, occasionally providing the same verbal response to a subsequent question (e.g., saying "in the hospital" to "Where are we?" and again to "What's your name?")
Verbigeration is repeating an exact phrase or sentence in succession, is not punctuated by examiner's subsequent questions or comments
Verbigeration is stereotyped, does not involve repetition of broader themes or topics
Item: Perseveration
From Item: Verbigeration

Difference: Motor Preservation involves transient continuation of action elicited physically by examiner or environment (i.e., behavioral initiation was stimulus-bound)
Stereotypy is performed spontaneously (i.e., has no connection to preceding events), typically repeated many times
Item: Perseveration
From Item: Stereotypy

Difference: Motor Perseverations are induced by physical interaction w/ examiner
Automatic Obedience is initiated based on verbal instruction or another social cue
Item: Motor Perseveration
From Item: Automatic Obedience

Difference: Combativeness is unprovoked, non-goal-directed aggression toward others, typically those in immediate surroundings
Excitement describes spontaneous onset of excessive activity typically involving entire body
Item: Combativeness
From Item: Excitement

Difference: Aggression is directed toward certain persons in particular, or done for another reason (i.e., revenge)
Aggression should not be scored as combativeness
Item: Combativeness
From Item: Goal-Directed Aggression

Difference: Combativeness is restricted to unprovoked, non-goal-directed aggression toward others
Impulsivity is broader, describing sudden, inappropriate behaviors of any type
Prevent double-coding: if all impulsive behaviors qualify as combativeness, score Combativeness only, not Impulsivity
Item: Combativeness
From Item: Impulsivity

Catatonia
Psychomotor syndrome w/ variants of movement:
Hypokinetic (↓)
Hyperkinetic (↑)
Parakinetic (abnormal)
presents w/ Primary Mental illness, Medical illness, Neurologic condition
odd, unusual relationship b/w Mental states, Motor activity, Behavioral context
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Q: [...] Catatonia
[...], [...] movements w/ increased activity
A: Hyperkinetic; Odd; Bizarre
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Malignant Catatonia
Autonomic Activation complicating any motoric subtype of catatonia
if severe and persistent, may be Fatal or cause severe, often Irreversible medical complications:
Thromboembolic disease, decubitus ulcers, contractures, aspiration pneumonia, malnutrition, dehydration
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Q: [...]
Standard instrument for detecting catatonia
Published in [year?]
A: Bush-Francis Catatonia Rating Scale (BFCRS); 1996
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Catatonia Clinical Assessment
requires general Observation, Physical examination, interventions Eliciting specific features
talk to patients as if Fully Aware, Cognizant to reduce fear, increase comfort, encourage participation w/ exam
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Timing of BFCRS
≥ 5 minutes to administer exam
exceptions:
Posturing / Catalepsy (15 min to differentiate scores 2 vs 3) and
Withdrawal (requires collateral for duration)
assessed as "Interval" or "State"
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Interval BFCRS
Initial assessment over time period of 8-, 12-, 24- hours
Extra: e.g., over nursing shift
Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Q: [...] BFCRS
assessed for [...] as a cross-section in time
to monitor [...]-term changes in clinical features
A: State; Follow-Up; Short
Extra: e.g., in response to lorazepam challenge
Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Do not score BFCRS items when known Neurological disease
Patients in Coma, Aphasia, Rigidity, etc.
may be confused w/ catatonic finding on BCFRS
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Q: Identify [n?] BFCRS items
when [...] is also present
to diagnose Catalonia
A: ≥ 4; Delirium
Extra: Syndromal overlap b/w Delirium and Catatonia
Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)
Wilson Crit Care Med 2018

Q: [...] Features of BFCRS
Rate item as [...] if uncertain about presence
Rate only items that are [...]
A: Equivocal; 0; Clearly Present
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Q: Are [...] in Catatonic Features to be Expected?
Yes, multiple presentations; no [...] is complete
A: Variations; Listing
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Q: [...]
[n?] items of BFCRS:
excitement, immobility, stereotypy, grimacing, staring, mutism, mannerism, verbigeration, echolalia / echopraxia, posturing / catalepsy, waxy flexibility, rigidity, negativism, withdrawal
[n?] additional items often included for ease of assessment:
gegenhalten, grasp reflex
A: Bush-Francis Catatonia Screening Instrument (BFCSI); 14; 2
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Speech-Prompt Catatonia
Patient provides Reflexive, verbal responses (word, phrase) to questions but is otherwise mute, uncooperative
Automatic, Elicited behavior
Score as Automatic Obedience in BFCRS
Rare subtype of catatonia
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Q: [...]
German for [...]
Scored in [...] item of BFCRS
A: Schnauzkrampf; "Scrunched Nose"; Grimacing
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)

Q: [...]
Patient obeys last command w/o stopping, until [...]
Score as [...] in BFCRS
A: Constancy; new command to stop; Automatic Obedience
Extra: Oldham, M. A. Bush-Francis Catatonia Rating Scale Training Manual and Coding Guide (2022)