Bush-Francis Catatonia Rating Scale

Bush-Francis Catatonia Screening

Excitement

Immobility / Stupor

Mutism

Staring

Posturing / Catalepsy

Grimacing

Echopraxia / Echolalia

Stereotypy

Mannerisms

Verbigeration

Rigidity

Negativism

Waxy Flexibility

Withdrawal

Positive Items: 0

Catatonia Screen Negative

0 of 14 items positive (<2): Negative catatonia screen. Catatonia is less likely.

Assesses catatonia severity and screens for catatonia in psychiatric and neurologic conditions.

Why Use

Catatonia may be hypokinetic or hyperkinetic and occur in psychotic, affective, and general medical conditions. It is commonly underdiagnosed and undertreated. This scale can help identify this syndrome in daily practice, as well as rate the severity of catatonia and monitor response to treatment.

When to Use

Patients with or without psychiatric history with characteristic symptoms of catatonia (e.g. altered consciousness, abnormal motor behavior).

Formula

Addition of the selected points: Variable Points Screening questions: if ≥2 are positive, full scale should be completed Excitement Extreme hyperactivity, constant motor unrest that appears non-purposeful; not attributed to akathisia or goal-directed agitation Absent 0 Excessive motion; intermittent 1 Constant motion; hyperkinetic without rest periods 2 Full-blown catatonic excitement; endless frenzied motor activity 3 Immobility/stupor Extreme hypoactivity, immobile, minimally responsive to stimuli Absent 0 Sits abnormally still; may interact briefly 1 Virtually no interaction with external world 2 Stuporous; non-reactive to painful stimuli 3 Mutism Verbally unresponsive or minimally responsive Absent 0 Verbally unresponsive to majority of questions; incomprehensible whisper 1 Speaks <20 words per 5 min 2 No speech 3 Staring Fixed gaze; little or no visual scanning of environment; decreased blinking Absent 0 Poor eye contact; repeatedly gazes <20 sec between shifting of attention; decreased blinking 1 Gaze held longer than 20 sec; occasionally shifts attention 2 Fixed gaze; non-reactive 3 Posturing/catalepsy Spontaneous maintenance of posture(s), including mundane (e.g. sitting or standing for long periods without reacting) Absent 0 <1 min 1 >1 min to <15 min 2 Bizarre posture, or mundane >15 min 3 Grimacing Maintenance of odd facial expressions Absent 0 <10 sec 1 <1 min 2 Bizarre expression(s) or maintained >1 min 3 Echopraxia/echolalia Mimicking of examiner’s movements/speech Absent 0 Occasional 1 Frequent 2 Constant 3 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 Absent 0 Occasional 1 Frequent 2 Constant 3 Mannerisms Odd, purposeful movements (hopping or walking tiptoe, saluting passers-by, or exaggerated caricatures of mundane movements); abnormality inherent in act itself Absent 0 Occasional 1 Frequent 2 Constant 3 Verbigeration Repetition of phrases or sentences (like a scratched record) Absent 0 Occasional 1 Frequent; difficult to interrupt 2 Constant 3 Rigidity Maintenance of a rigid position despite efforts to be moved; exclude if cog-wheeling or tremor present Absent 0 Mild resistance 1 Moderate 2 Severe; cannot be repostured 3 Negativism Apparently motiveless resistance to instructions or attempts to move/examine patient; contrary behavior (does exact opposite of instruction) Absent 0 Mild resistance and/or occasionally contrary 1 Moderate resistance and/or frequently contrary 2 Severe resistance and/or continually contrary 3 Waxy flexibility During reposturing of patient, patient offers initial resistance before allowing themselves to be repositioned, similar to that of a bending candle Absent 0 Present 3 Withdrawal Refusal to eat, drink, and/or make eye contact Absent 0 Minimal PO intake/interaction for <1 day 1 Minimal PO intake/interaction for >1 day 2 No PO intake/interaction for ≥1 day 3 Additional questions: to be completed if ≥2 of the above are positive Impulsivity Patient suddenly engages in inappropriate behavior (e.g. runs down hallway, starts screaming, or takes off clothes) without provocation; afterwards can give no, or only a facile explanation Absent 0 Occasional 1 Frequent 2 Constant or not redirectable 3 Automatic obedience Exaggerated cooperation with examiner’s request or spontaneous continuation of movement requested Absent 0 Occasional 1 Frequent 2 Constant 3 Mitgehen “Anglepoise lamp” arm raising in response to light pressure of finger, despite instructions to the contrary Absent 0 Present 3 Gegenhalten Resistance to passive movement which is proportional to strength of the stimulus; appears automatic rather than willful Absent 0 Present 3 Ambitendency Patient appears motorically “stuck” in indecisive, hesitant movement Absent 0 Present 3 Grasp reflex Per neurological exam Absent 0 Present 3 Perseveration Repeatedly returns to same topic or persists with movement Absent 0 Present 3 Combativeness Usually in an undirected manner, with no, or only a facile explanation afterwards Absent 0 Occasionally strikes out; low potential for injury 1 Frequently strikes out; moderate potential for injury 2 Serious danger to others 3 Autonomic abnormality Parameters: temperature, BP, pulse, respiratory rate, diaphoresis Absent 0 Abnormality of 1 parameter (excluding pre-existing hypertension) 1 Abnormality of 2 parameters 2 Abnormality of ≥3 parameters 3

Pearls / Pitfalls

The most common symptoms of catatonia, which can be considered “red flags” to trigger use of this scale, include staring, mutism, and immobility. May be used both for initial diagnosis and to monitor treatment response. The full scale is 23 items, with the first 14 questions comprising the screening instrument (Bush-Francis Catatonia Screening Instrument). If ≥2 of the first 14 questions are positive, this indicates a positive screening and should prompt completion of 9 additional items for a total of 23 items (Bush-Francis Catatonia Rating Scale). Takes roughly five minutes to complete. Many scale items require understanding of traditional psychiatric terminology and how to test them, such as the following: Echopraxia: the provider will need to perform a dramaticized movement such as scratching their head. Automatic obedience: the provider will need to provide a command that people would not typically follow, such as “stick out your tongue, I'm going to put a pin in it.”

Management

First line management for catatonia is a trial of lorazepam, which may be given PO, IM, or IV depending on the patient’s condition (IV having the quickest response time). An accurate lorazepam trial is given as 1-2 mg, then response is monitored over three h ours. If there is no response and no adverse effects, such as respiratory depression, sedation, or further impaired consciousness , the n another lorazepam dose can be given with response monitored over 3 hours. Decrease in the Bush-Francis Catatonia Rating Scale by 50% indicates positive treatment response ( Rasmussen 2016 ).

Critical Actions

Monitor for respiratory depression, sedation, or further impairment in consciousness during medication management of catatonia.

More Information

Interpretation: Higher scores indicate greater severity of catatonia.