A Subjective Units of Distress Scale (SUDS), also known as the Subjective Units of Disturbance Scale), is a scale ranging from 0 to 10 measuring the subjective intensity of disturbance or distress currently experienced by an individual.
Respondents provide a self report of where they are on the scale. The SUDS may be used as a benchmark for a professional or observer to evaluate the progress of treatment. In desensitisation-based therapies, and the patients’ regular self assessments enable them to guide the clinician repeatedly as part of the therapeutic dialogue.
The SUD-level was developed by Joseph Wolpe in 1969. It has been used in cognitive-behavioural treatments for anxiety disorders (e.g. exposure practices and hierarchy) and for research purposes.
There is no hard and fast rule by which a patient can self assign a SUDS rating to his or her disturbance or distress, hence the name subjective.
Some guidelines are:
The intensity recorded must be as it is experienced now.
Constriction or congestion or tensing of body parts indicates a higher SUDS than that reported.
The Scale
There a number of version of the scale, and the below is for illustration only:
10 = Feels unbearably bad, beside yourself, out of control as in a nervous breakdown, overwhelmed, at the end of your rope. You may feel so upset that you don’t want to talk because you can’t imagine how anyone could possibly understand your agitation.
9 = Feeling desperate. What most people call a 10 is actually a 9. Feeling extremely freaked out to the point that it almost feels unbearable and you are getting scared of what you might do. Feeling very, very bad, losing control of your emotions.
8 = Freaking out. The beginning of alienation.
7 = Starting to freak out, on the edge of some definitely bad feelings. You can maintain control with difficulty.
6 = Feeling bad to the point that you begin to think something ought to be done about the way you feel.
5 = Moderately upset, uncomfortable. Unpleasant feelings are still manageable with some effort.
4 = Somewhat upset to the point that you cannot easily ignore an unpleasant thought. You can handle it OK but don’t feel good.
3 = Mildly upset. Worried, bothered to the point that you notice it.
2 = A little bit upset, but not noticeable unless you took care to pay attention to your feelings and then realize, “yes” there is something bothering me.
1 = No acute distress and feeling basically good. If you took special effort you might feel something unpleasant but not much.
0 = Peace, serenity, total relief. No more anxiety of any kind about any particular issue.
Utility Does Not Require Precision
In using SUDS in a therapeutic setting, the therapist does not necessarily define the scale, because one of the benefits of asking a patient or client for a SUDS score is that it is simple. Typically, you can ask the client, “On a scale of zero to ten, where zero is the best you can feel and ten is the worst, how do you feel right now?”
The purpose of this question is to enable the patient or client to notice improvements, and the inherent difference between one person’s subjective scale and another person’s is irrelevant to therapy with either individual. Our brains are sophisticated enough that they can usually summarize a large amount of data very quickly, and often accurately.
There is a possibility that in some forms of therapy, the patient will want to see progress and will therefore report progress that isn’t objectively present – a type one error from a statistical point of view. While both type I and type II errors are important in research situations, type one errors can have a therapeutic utility in clinical situations, in which they can provide an indirect opportunity for positive autosuggestion – much like the indirect suggestions employed in Eriksonian hypnosis.
Thus, since the main use of SUDS is for clinical purposes, rather than research purposes, the imprecise nature of the scale is relatively unimportant to its main users: patients and clinicians.
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The Holmes and Rahe stress scale is a list of 43 stressful life events that can contribute to illness.
The test works via a point accumulation score which then gives an assessment of risk. The American Institute of Stress for instance, regards a score of 300 or more as an “80% chance of health breakdown within the next 2 years”. While there is good evidence that chronic stress can lead to ill health, there is not much evidence to support the ranking of stressful life events in this manner.
Brief History
In 1967, psychiatrists Thomas Holmes and Richard Rahe examined the medical records of over 5,000 medical patients as a way to determine whether stressful events might cause illnesses. Patients were asked to tally a list of 43 life events based on a relative score. A positive correlation of 0.118 was found between their life events and their illnesses.
Their results were published as the Social Readjustment Rating Scale (SRRS), known more commonly as the Holmes and Rahe Stress Scale. Subsequent validation has supported the links between stress and illness.
Supporting Research
Rahe carried out a study in 1970 testing the validity of the stress scale as a predictor of illness. The scale was given to 2,500 US sailors and they were asked to rate scores of ‘life events’ over the previous six months. Over the next six months, detailed records were kept of the sailors’ health. There was a +0.118 correlation between stress scale scores and illness, which was sufficient to support the hypothesis of a link between life events and illness.
In conjunction with the Cornell medical index assessing, the stress scale correlated with visits to medical dispensaries, and the H&R stress scale’s scores also correlated independently with individuals dropping out of stressful underwater demolitions training due to medical problems. The scale was also assessed against different populations within the United States (with African, Mexican and White American groups). The scale was also tested cross-culturally, comparing Japanese and Malaysian groups with American populations.
Scale
Score of 300+: At risk of illness.
Score of 150-299: Risk of illness is moderate (reduced by 30% from the above risk).
Score <150: Only have a slight risk of illness.
Adults
The sum of the life change units of the applicable events in the past year of an individual’s life gives a rough estimate of how stress affects health.
Life Event
Life Change Units
Death of a Spouse
100
Divorce
73
Marital Separation
65
Imprisonment
63
Death of a Close Family Member
63
Personal Injury or Illness
53
Marriage
50
Dismissal from Work
47
Marital Reconciliation
45
Retirement
45
Change in Health of Family Member
44
Pregnancy
40
Sexual Difficulties
39
Gain a New Family Member
39
Business Readjustment
39
Change in Financial State
38
Death of a Close Friend
37
Change to Different Line of Work
36
Change in Frequency of Arguments
35
Major Mortgage
32
Foreclosure of Mortgage/Loan
30
Change in Responsibilities at Work
29
Child Leaving Home
29
Trouble with In-Laws
29
Outstanding Personal Achievement
28
Spouse Starts or Stops Work
26
Beginning or End of School
26
Change in Living Conditions
25
Revision of Personal Habits
24
Trouble with Boss
23
Change in Working Hours or Conditions
20
Change in Residence
20
Change in Schools
20
Change in Recreation
19
Change in Church Activities
19
Change in Social Activities
18
Minor Mortgage/Loan
17
Change in Sleeping Habits
16
Change in Number of Family Reunions
15
Change in Eating Habits
15
Vacation
13
Major Holiday
12
Minor Violation of Law
11
Non-Adults
A modified scale has also been developed for non-adults. Similar to the adult scale, stress points for life events in the past year are added and compared to the rough estimate of how stress affects health.
Life Event
Life Change Units
Death of a Parent
100
Unplanned Pregnancy/Abortion
100
Getting Married
95
Divorce of Parents
90
Acquiring a Visible Deformity
80
Fathering a Child
70
Jail Sentence of Parent of Over One Year
70
Marital Separation of Parents
69
Death of a Brother or Sister
68
Change in Acceptance by Peers
67
Unplanned Pregnancy of Sister
64
Discovery of Being an Adopted Child
63
Marriage of Parent to Step-Parent
63
Death of a Close Friend
63
Having a Visible Congenital Deformity
62
Serious Illness Requiring Hospitalisation
58
Failure of a Grade in School
56
Not Making an Extracurricular Activity
55
Hospitalisation of a Parent
55
Jail Sentence of Parent for over 30 Days
53
Breaking Up with Boyfriend or Girlfriend
53
Beginning to Date
51
Suspension from School
50
Becoming Involved with Drugs/Alcohol
50
Birth of a Brother or Sister
50
Increase in Arguments between Parents
47
Loss of Job by Parent
46
Outstanding Personal Achievement
46
Change in Parent’s Financial Status
45
Accepted at College of Choice
43
Being a Senior in High School
42
Hospitalisation of a Sibling
41
Increased Absence of Parent from Home
38
Brother or Sister Leaving Home
37
Addition of Third Adult to Family
34
Becoming a Full-Fledged Member of a Church
31
Decrease in Arguments between Parents
27
Decrease in Arguments with Parents
26
Mother or Father Beginning Work
26
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The Brief Psychiatric Rating Scale (BPRS) is a rating scale which a clinician or researcher may use to measure psychiatric symptoms such as depression, anxiety, hallucinations and unusual behaviour.
The scale is one of the oldest, most widely used scales to measure psychotic symptoms and was first published in 1962.
Brief History
The BPRS was initially developed by John E. Overall and Donald R. Gorham. It was created for the purpose of being able to quickly assess the patient’s psychiatric symptoms prior, during, or following a treatment. The items of the test were generated from conducting factor analysis on the Multidimensional Scale for Rating Psychiatric Patients and the Inpatient Multidimensional Psychiatric Scale. Sixteen factors were found from the analysis, which served as the building blocks for the BPRS. Later research in 1968 added two more factors to the BPRS, which were excitement and disorientation.
Test Format
The BPRS consists of 18 items measuring the following factors:
It uses a seven-item Likert scale with the following values:
1 = “not present”.
2 = “very mild”.
3 = “mild”.
4 = “moderate”.
5 = “moderately severe”.
6 = “severe”.
7 = “extremely severe”.
The test is administered in tandem with a series of interviews conducted by at least two clinicians to ensure interrater reliability of the assessment.
Usage
The BPRS is intended for use on adult psychiatric patients and has been validated for use in elderly populations. A version designed for children called the Brief Psychiatric Rating Scale Children was also developed by Overall and Betty Pfeifferbaum, with different scale structures and factors.
Further Development
An expanded version of the test was created in 1993 by D. Lukoff, Keith H. Nuechterlein, and Joseph Ventura.
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The General Behavior Inventory (GBI) is a 73-question psychological self-report assessment tool designed by Richard Depue and colleagues to identify the presence and severity of manic and depressive moods in adults, as well as to assess for cyclothymia.
It is one of the most widely used psychometric tests for measuring the severity of bipolar disorder and the fluctuation of symptoms over time. The GBI is intended to be administered for adult populations; however, it has been adapted into versions that allow for juvenile populations (for parents to rate their offspring), as well as a short version that allows for it to be used as a screening test.
The GBI was originally made as a self-report instrument for college students and adults to use to describe their own history of mood symptoms. The original item set included clinical characteristics and associated features in addition to the diagnostic symptoms of manic and depressive states in the current versions of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. The first set of 69 items was increased to 73, with the final version having 73 mood items and 6 additional questions to check the validity of responses (but which did not figure in the scale scores). The self report version of the GBI has been used in an extensive programme of research, accruing evidence of many facets of validity. Because of its length and high reading level, there also have been many efforts to develop short forms of the GBI.
7 Up 7 Down Inventory (7U7D)
The 7 Up-7 Down (7U7D) is a 14-item measure of manic and depressive tendencies that was carved from the full length GBI. This version is designed to be applicable for both youths and adults, and to improve separation between both mania and depressive conditions. It was developed via factor analysis from nine separate samples pooled into two age groups, ensuring applicability for use in youth and adults.
A sleep scale also has been carved from the GBI, using the seven items that ask about anything directly related to sleep.
Parent Report on the GBI (P-GBI)
The P-GBI is an adaptation of the GBI, consisting of 73 Likert scale items rated on a scale from 0 (“Never or Hardly Ever”) to 3 (“Very often or Almost Constantly”). It consists of two scales: a depressive symptoms (46 items) and a hypomanic/biphasic (mixed) symptoms (28 items).
Parent Short Forms
Again, due to the length of the full version, several short forms have been built and tested in multiple samples that may be more convenient to use in clinical work. These include 10 item mania, two alternate 10 item depression forms, and the seven item Sleep scale. All have performed as well or better than the self-report version when completed by an adult familiar with the youth’s behaviour (typically a parent).
The PGBI-10M is a brief (10-item) version of the PGBI that was validated for clinical use for patients presenting with a variety of different diagnoses, including frequent comorbid conditions. It is administered to parents for them to rate their children between ages 5-17. The 10 items include symptoms such as elated mood, high energy, irritability and rapid changes in mood and energy as indicators of potential juvenile bipolar disorder. The PhenX Toolkit uses this instrument as its child protocol for Hypomania/Mania Symptoms.
Teacher Report on the GBI
One study had a large sample of teachers complete the GBI to describe the mood and behaviour of youths age 5 to 18 years old. The results indicated that there were many items that teachers did not have an opportunity to observe the behaviour (such as the items asking about sleep), and others that teachers often chose to skip. Even after shortening the item list to those that teachers could report about, the validity results were modest even though the internal consistency reliability was high. The results suggested that it was challenging for teachers to tell the difference between hypomanic symptoms and symptoms attributable to attention-deficit/hyperactivity disorder, which is much more common in the classroom. The results aligned with findings from a large meta-analysis that teacher report had the lowest average validity across all mania scales compared to adolescent or parent report on the same scales. Based on these results, current recommendations are to concentrate on parent and youth report, and not use teacher report as a way of measuring hypomanic symptoms in youths.
Psychometric Properties
The GBI has been used extensively in research, including clinical samples, college students, longitudinal, treatment, and other studies. However, no normative data exist to calibrate scores in the general population.
Reliability
The GBI has exceptionally high internal consistency because it has long scales with a large number of items. The GBI shows high reliability whether completed as a self report or as a caregiver report about youth behaviour.
Retest reliability also is good over a week or two week period, although the GBI’s length makes it tedious to complete frequently.
Interpretation
GBI Scoring
The current GBI questionnaire includes 73 Likert-type items which reflect symptoms of different moods. The original version of the GBI used case scoring where items were given values ranging from 1-4. Symptoms that were rated as 1 or 2 were considered to be absent and symptoms rated as 3 or 4 were considered to be present. However, if each item were to receive one of four scores, the authors of the GBI decided Likert scaling would be a better scoring option. The items on the GBI are now scaled from 0-3 rated as 0 (never or hardly ever present), 1 (sometimes present), 2 (often present), and 3 (very often or almost constantly present).
PGBI-10M
For the PGBI-10M, the scores from each question are added together to form a total score, with higher scores indicating a greater severity of symptoms. Scores range from 0 to 30. Low scores of 5 and below indicate a very low risk of a bipolar diagnosis. High scores of 18 and over indicate a high risk of a diagnosis of bipolar disorder, increasing the likelihood by a factor of seven or greater. Several peer-reviewed research studies support the P-GBI as a reliable and valid measure of bipolar in children and adolescents. It is recommended to be used as part of an assessment battery in the diagnosis of juvenile bipolar disorder.
Limitations
The GBI is free for use clinically and in research. The reading level and length make it challenging for some people to complete. Being a self-report questionnaire, the GBI is not known to have any adverse effects on patients beyond the potential of causing minor distress.
Research
Shorter versions of the GBI have been validated for research and clinical use. For instance, the PGBI-10M is currently being tested as part of a large longitudinal study investigating the course of early symptoms of mania in children[citation needed], with preliminary studies indicating its clinical efficacy in differentiating juvenile bipolar disorder from youth with other diagnoses.
It asks about 32 behaviours and mental states that are either aspects of hypomania or features associated with mood disorders. It uses short phrases and simple language, making it easy to read. The University of Zurich holds the copyright, and the HCL-32 is available for use at no charge. More recent work has focused on validating translations and testing whether shorter versions still perform well enough to be helpful clinically. Recent meta-analyses find that it is one of the most accurate assessments available for detecting hypomania, doing better than other options at recognising bipolar II disorder.
Development and Brief History
The Hypomania Checklist was built as a more efficient screening measure for hypomania, to be used both in epidemiological research and in clinical use. Existing measures for bipolar disorder focused on identifying personality factors and symptom severity instead of the episodic nature of hypomania or the possible negative consequences in behavioural, affective, or cognitive changes associated. These measures were mostly used in non-clinical populations to identify individuals at risk and were not used as screening instruments. The HCL-32 is a measure intended to have high sensitivity to direct clinicians from many countries to diagnosing individuals in a clinical population with bipolar disorder, specifically bipolar II disorder.
Initially developed by Jules Angst and Thomas Meyer in German, the questionnaire was translated into English and translated back to German to ensure accuracy. The English version of the HCL has been used as the basis for translation in other languages through the same process. The original study that used the HCL in an Italian and a Swiss sample noted the measure’s high sensitivity and a lower sensitivity than other used measures.
The scale includes a checklist of 32 possible symptoms of hypomania, each rated yes or no. The rating “yes” would mean the symptom is present or this trait is “typical of me,” and “no” would mean that the symptom is not present or “not typical” for the person.
Limitations
The HCL suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimised by the person completing them. Like all questionnaires, the way the instrument is administered can influence the final score. If a patient is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations may elicit a different response compared to administration via a postal survey.
Similar reliability scores were found when only using 16 item assessments versus the traditional 32-item format of the HCL-32. A score of at least 8 items was found valid and reliable for distinguishing Bipolar Disorder and Major Depressive Disorder. In a study, 73% of patients who completed the HCL-32 R1 were true bipolar cases identified as potential bipolar cases. However, the HCL-32 R1 does not accurately differentiate between Bipolar I and Bipolar II. However, the 16-item HCL has not been tested as a standalone section in a hospital setting. In addition, while the HCL-32 is a sensitive instrument for hypomanic symptoms, it does not distinguish between bipolar I and bipolar-II disorders. The HCL-32 has not been compared with other commonly used screening tools for bipolar disorder, such as the Young Mania Rating Scale (YMRS)and the General Behaviour Inventory (GBI). The online version of the HCL has been shown to be as reliable as the paper version.
The Schedule for Affective Disorders and Schizophrenia (SADS) is a collection of psychiatric diagnostic criteria and symptom rating scales originally published in 1978.
It is organised as a semi-structured diagnostic interview. The structured aspect is that every interview asks screening questions about the same set of disorders regardless of the presenting problem; and positive screens get explored with a consistent set of symptoms. These features increase the sensitivity of the interview and the inter-rater reliability (or reproducibility) of the resulting diagnoses. The SADS also allows more flexibility than fully structured interviews: Interviewers can use their own words and rephrase questions, and some clinical judgment is used to score responses.
There are three versions of the schedule:
The regular SADS;
The lifetime version (SADS-L); and
A version for measuring the change in symptomology (SADS-C).
Although largely replaced by more structured interviews that follow diagnostic criteria such as DSM-IV and DSM-5, and specific mood rating scales, versions of the SADS are still used in some research papers today.
Relationship with the Research Diagnostic Criteria
The SADS was developed by the same group of researchers as the Research Diagnostic Criteria (RDC). While the RDC is a list of diagnostic criteria for psychiatric disorders, the SADS interview allows diagnoses based on RDC criteria to be made, and also rates subject’s symptoms and level of functioning.
K-SADS
The K-SADS (or Kiddie-SADS) is a version of the SADS adapted for school-aged children of 6–18 years. There are various different versions of the K-SADS, each varying slightly in terms of disorders and specific symptoms covered, as well as the scale range used. All of the variations are still semi-structured interviews, giving the interviewer more flexibility about how to phrase and probe items, while still covering a consistent set of disorders.
The K-SADS-E (Epidemiological version) was developed for epidemiological research. It focused on current issues and episodes only. Most of the items used a four point rating scale.
The K-SADS-PL (Present and Lifetime version) is administered by interviewing the parent(s), the child, and integrating them into a summary rating that includes parent report, child report, and clinical observations during the interview. The interview covers both present issues (i.e., the reason the family is seeking an evaluation) as well as past episodes of the disorders. Most items use a three point rating scale for severity (not present, subthreshold, and threshold – which combines both moderate and severe presentations). It has been used with preschool as well as school-aged children. A 2009 working draft removed all reference to the DSM-III-R criteria (which were replaced with the publication of the DSM-IV in 1994) and made some other modifications. A DSM-5 version is being prepared and validated.
The WASH-U K-SADS (Washington University version) added items to the depression and mania modules and used a six point severity rating for severity.
The Research Diagnostic Criteria (RDC) are a collection of influential psychiatric diagnostic criteria published in late 1970s under auspices of Statistics Section NY Psychiatric Institute, authors were Spitzer, R L; Endicott J; Robins E. PMID 1153649; As psychiatric diagnoses widely varied especially between the USA and Europe, the purpose of the criteria was to allow diagnoses to be consistent in psychiatric research.
Some of the criteria were based on the earlier Feighner Criteria, although many new disorders were included; “The historical record shows that the small group of individuals who created the Feighner criteria instigated a paradigm shift that has had profound effects on the course of American and, ultimately, world psychiatry.”
The RDC is important in the history of psychiatric diagnostic criteria as the DSM-III was based on many of the RDC descriptions, head of DSM III Edition was R L Spitzer.
The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) is a semi-structured interview aimed at early diagnosis of affective disorders such as depression, bipolar disorder, and anxiety disorder. There are currently four different versions of the test that are structured to include interviews with both the child and the parents or guardians.
The K-SADS serves to diagnose childhood mental disorders in school-aged children 6-18. The different adaptations of the K-SADS were written by different researchers and are used to screen for many affective and psychotic disorders. Versions of the K-SADS are semi-structured interviews administered by health care providers or highly trained clinical researchers, which gives more flexibility to the interviewer about how to phrase and probe items, while still covering a consistent set of disorders. Due to its semi-structured interview format, time to complete the administration varies based on the youth/adult being interviewed. Most versions of the K-SADS also include “probes”, if these are endorsed, another diagnostic category will be reviewed. If the probe is not endorsed, additional symptoms for that particular disorder will not be queried.
The K-SADS has been found to be reliable and valid in multiple research and treatment settings.
The Schedule for Affective Disorders and Schizophrenia for School Aged Children, or K-SADS, was originally created as an adapted version of the Schedule for Affective Disorders and Schizophrenia, a measure for adults. The K-SADS was written by Chambers, Puig-Antich, et al. in the late 1970s. The K-SADS was developed to promote earlier diagnosis of affective disorders and schizophrenia in children in a way that incorporates reports by both the child and parent and a “summary score” by the interviewer based on observations and teacher ratings.
The first version of the K-SADS differed from other tests on children because it relied on answers to interview questions rather than observances during games and interactions. The 1990s led to the creation of different versions of the K-SADS for different purposes, such as ascertaining lifetime diagnoses (K-SADS-E) or focusing on current episodes (K-SADS-P).
Versions
KSADS-Present Version (KSADS-P)
The KSADS-P was the first version of the K-SADS, developed by Chambers and Puig-Antich in 1978 as a version of the Schedule for Affective Disorders and Schizophrenia adapted for use with children and adolescents 6-19 years old. This version rephrased the SADS to make the wording of the questionnaire pertain to a younger age group. For example, mania symptoms in children might be manifest differently than in adulthood (e.g. children might have not have the same opportunity to spend money impulsively, nor would they likely have access to credit cards or checking accounts; instead, they might give away all their favourite toys or empty their parent’s wallet to gain spending money). The KSADS-P is a structured interview given by trained clinicians or clinical researchers who interview both the child and the parent. This original version assesses symptoms that have occurred in the most current episode (within the week preceding the interview), as well as symptoms that have occurred within the last 12 months. The KSADS-P has many limitations: it does not assess lifetime symptoms and history, does not include many psychiatric diagnoses of interest in childhood (such as autistic spectrum disorders), and does not include diagnosis specific impairment ratings.
KSADS-Present and Lifetime Version (KSADS-PL)
The K-SADS-PL is used to screen for affective and psychotic disorders as well as other disorders, including, but not limited to Major Depressive Disorder, Mania, Bipolar Disorders, Schizophrenia, Schizoaffective Disorder, Generalized Anxiety, Obsessive Compulsive Disorder, Attention Deficit Hyperactivity Disorder, Conduct Disorder, Anorexia Nervosa, Bulimia, and Post-Traumatic Stress Disorder. This semi-structured interview takes 45-75 minutes to administer. It was written by Joan Kaufman, Boris Birmaher, David Brent, Uma Rao, and Neal Ryan. The majority of items in the K-SADS-PL are scored using a 0-3 point rating scale. Scores of 0 indicate no information is available; scores of 1 suggest the symptom is not present; scores of 2 indicate sub-threshold presentation and scores of 3 indicate threshold presentation of symptoms. The KSADS-PL has six components:
Component
Description
Unstructured Introductory Interview – Developmental History
The first part of the interview asks about developmental history and the history of the presenting problem. The interviewer takes detailed notes on the record sheet. Prompts cover basic demographic information, physical and mental health history and prior treatments, current complaints, and the youth’s relations with friends, family, school, and hobbies. This section allows flexibility for the interviewer to collect more information on questions that need elaboration.
Diagnostic Screening Interview
The diagnostic screening interview reviews the most severe current and past symptoms. There are probes and scoring criteria for each symptom presented. Symptoms of disorders are grouped into modules. If the patient does not display any current or past symptoms for the screening questions, then the rest of the module’s questions do not need to be asked.
Completion Checklist Supplement
A supplemental checklist is used to screen for additional disorders.
Appropriate Diagnostic Supplements
These supplements review presence/absence of symptoms for other disorders, including anxiety disorders, behavioural disorders, and substance abuse.
Summary Lifetime Diagnosis Checklist
Based on the previous sections, this section summarises which disorders have been present from first episode to now.
Children’s Global Assessment Scale (C-GAS)
Scores the child’s level of functioning.
KSADS-Epidemiological (KSADS-E)
The KSADS-E, which is the epidemiological version of the KSADS, is a tool to interview parents about possible psychopathology in children from preschool onward. It was developed by Puig-Antich, Orvaschel, Tabrizi, and Chambers in 1980 as a structured interview. The tool examines both past and current episodes, focusing on the most severe past episode and the most current episode. However, this tool does not rate symptom severity; it should only be used to assess presence or absence of symptomatology. This version of the K-SADS introduced screening questions, which, if negative, allowed skipping the remaining diagnostic probes. Furthermore, the K-SADS-E also includes “skip out” criteria when assessing other diagnostic disorders (ADHD, PTSD, etc.), allowing those that screen positive to immediately be interviewed for all of the symptoms regarding that diagnosis, and those that screened negative could “skip out” of being interviewed on the remaining symptoms.
WASH-U-KSADS
The WASH-U version of the K-SADS was written by Barbara Geller and colleagues in 1996. It is a modified version of the 1986 K-SADS. This version is like many other versions of the K-SADS in that it is semi-structured, administered by clinicians to both parent and child separately, and assesses present episodes. However, this version specifically expands the mania section in order to be more applicable to pre-pubertal mania. In particular, it queries presence/absence of rapid cycling. It also includes a section on multiple other DSM-IV diagnoses, and examines both present and lifetime symptoms as well as symptom onset and offset items. These modifications made this specific version particularly useful for phenomenology studies.
KSADS Mania Rating Scale (KMRS) and Depression Rating Scale (KDRS) It also is possible to use the items in the mania and depression modules of some versions of the KSADS to get an interview-based rating of the severity of mood problems. The KMRS and KDRS use a 1 to 6 rating format (the same as in the WASH-U, -P, and PL-Plus versions). Adding up the items provides a measure of the total symptom burden. The KMRS assess 21 symptoms related to mania, hypomania, and rapid cycling. Each item is rated on a 0-6 rating scale. Scores of 0 suggest no information is available (missing data); scores of 1 suggest the symptom is not present at all; scores of 2 suggest the symptom is slightly present; scores of 3 suggest the symptom is mildly severe; scores of 4 suggest the symptom is moderately severe; scores of 5 suggest the symptom is severe; and scores of 6 suggest the symptom is extremely severe. Items with scores of 4 or higher are clinically significant/problematic. Trained clinicians or clinical researchers administer the assessment to both the child and the parent, which each provide their own separate score for each item (P and C), and the total score encompasses the sum of all of the items (S).
The KMRS is an alternative to the Young Mania Rating Scale designed by Young et al. (frequently referred to as the YMRS). The YMRS is more well-known and widely used, but because it was written in 1978, it does not include all of the symptoms of mania from ICD-9 or ICD-10 (nor DSM-IV or DSM-5), as it predated them all. The YMRS was also designed for completion by nurses at the end of their eight-hour shift on an inpatient unit, observing adult patients. The KMRS has several advantages in comparison: It covers all the symptoms used in current versions of ICD and DSM, it was designed for use with children and teenagers, and it was written and validated as an interview. Studies have found excellent internal consistency and inter-rater reliability, as well as exceptionally high correlation with the YMRS. Similarly, the KDRS would be analogous to the Child Depression Rating Scale-Revised. The CDRS-R was also designed to be done as an interview, but the item content predates the current ICD and DSM and omits some important symptoms. The KDRS also shows strong reliability (internal consistency and inter-rater) and exceptionally high correlations with the KDRS.
Impact
The K-SADS is used to measure previous and current symptoms of affective, anxiety, psychotic, and disruptive behaviour disorders. The K-SADS has become one of the most widely used diagnostic interviews in research, particular for projects focused on mood disorders.
The K-SADS-PL has been written and translated into 16 different languages, including Korean, Hebrew, Turkish, Icelandic, and Persian. The K-SADS-PL is also available in several Indian dialects including Kannada, Marathi, Tamil and Telugu.
Limitations
One limitation of the K-SADS is that it requires extensive training to give properly, including observation techniques, score calibration, and re-checks to test inter-rater reliability.
The Child Mania Rating Scales (CMRS) is a 21-item diagnostic screening measure designed to identify symptoms of mania in children and adolescents aged 9-17 using diagnostic criteria from the DSM-IV, developed by Pavuluri and colleagues.
There is also a 10-item short form. The measure assesses the child’s mood and behaviour symptoms, asking parents or teachers to rate how often the symptoms have caused a problem for the youth in the past month. Clinical studies have found the CMRS to be reliable and valid when completed by parents in the assessment of children’s bipolar symptoms. The CMRS also can differentiate cases of paediatric bipolar disorder from those with ADHD or no disorder, as well as delineating bipolar subtypes. A meta-analysis comparing the different rating scales available found that the CMRS was one of the best performing scales in terms of telling cases with bipolar disorder apart from other clinical diagnoses. The CMRS has also been found to provide a reliable and valid assessment of symptoms longitudinally over the course of treatment. The combination of showing good reliability and validity across multiple samples and clinical settings, along with being free and brief to score, make the CMRS a promising tool, especially since most other checklists available for youths do not assess manic symptoms.
Background
The Child Mania Rating Scale (CMRS) was created as a complement already existing measures like the Altman Self-Rating Mania Scale and the Young Mania Rating Scale, which were formulated for adults. The purpose of the CMRS is to both assess the symptoms of mania in paediatric bipolar disorder, and to accurately discriminate the symptoms of mania from symptoms of ADHD. It is important that the CMRS accurately discriminate from symptoms of ADHD because core symptoms of adolescent Bipolar Disorder and ADHD are shared between the two disorders: hyperactivity, impulsivity, and distractibility. The CMRS was designed specifically for younger children who may or may not have the ability to accurately answer questions about their behaviour. As a result, the questionnaire is filled out by parents are/or caregivers who work with the children on a daily basis. Previous mania scales were designed for use by either the clinician or the patient. Therefore, the CMRS is unique in that it allows parents and caregivers to contribute information about their child’s symptoms. This is especially important in cases where the child may be too young to fill out the questionnaires themselves.
Historically, effective rating and diagnosis of mania has been limited. Though many mania scales have been tested on adult populations, the Young Mania Rating Scale (YMRS) – which was tested against the child version (CMRS) as standard measure for screening mania- is the only adult scale that has also been studied for validity and reliability in prepubertal children. Previous attempts include the Beigel Scale/Manic State Rating Scale (MSRS) and the Patterson Scale, which used nurse and clinician reports to rate levels of mania. Neither scale effectively and consistently captured levels of mania in patients. Other measures of paediatric mania are generally limited because they are completed by the clinician, introducing potential for bias, and because they lack the depth necessary to differentiate between patient-specific ways in which symptoms are presented. The CMRS Parent and Teacher versions attempt to address some of the limitations by including a checklist that can gather information about behaviour at home, school, and other settings, rather than focusing only on what a clinician could directly observe. One study examined the accuracy of a shortened version of the CMRS-P, which included only 10 items, and found that its accuracy was similar to the full scale.
Typically, the CMRS takes only 10-15 minutes to administer. The questions ask about behaviour-specific actions and tendencies the child may have exhibited within the past month. The parent rates the behaviour on a scale from 1 to 4, where 1=never/rarely, 2=sometimes, 3=often, and 4=very often. A clinician examines the total score and determines if the child has ADHD or Bipolar Disorder. If a diagnosis Bipolar Disorder is deemed to be appropriate, the clinician will also determine the sub-type.
Versions
There is a short version (10 items) of the CMRS called the Brief CMRS/Brief CMRS-P. The shorter version was created because a shorter version is preferred to longer assessments if the shorter gives similar accuracy, which it does. Additionally, there is a teacher’s version of the CMRS called the CMRS-Teacher (CMRS-T).
Reliability and Validity
Reliability
Table 1: Rubric for evaluating norms and reliability for the Child Mania Rating Scale.
Designed originally as a self-report scale; parent and youth report correlate about the same as cross-informant scores correlate in general.
Test-Retest Reliability
Adequate
r = .96 over 1 week. Data on test-retest reliability over longer periods are needed.
Repeatability
Not published
No published studies formally checking repeatability.
Construct validity analyses (Exploratory Factor Analysis and Confirmatory Factor Analysis) for the CMRS-P indicated that the scale is unidimensional. Internal consistency measured by Cronbach’s alpha was .96 in a sample consisting of ADHD, Bipolar, and healthy control participants. In a sample of participants with bipolar disorder, the cronbach’s alpha was 91. Additionally, it has the ability to accurately differentiate paediatric bipolar disorder from ADHD and healthy controls greater than 90% of the time.
The teacher version (CMRS-T) also has 21 items. The internal consistency, measured by Cronbach’s alpha, was .86. Correlations between the parent and teacher versions of the CMRS range from .23 to .27. The CMRS teacher version has not been shown to discriminate bipolar from nonbipolar cases at better than chance levels and is not recommended for use in clinical practice for diagnosing bipolar disorder in children.
Validity
Table 2: Evaluation of validity and utility for the Child Mania Rating Scale
Criterion
Rating (Adequate, Good, Excellent, Too Good)
Explanation
Content Validity
Excellent
Covers both DSM diagnostic symptoms and a range of associated features. Consistently distinguishes between PBP sub-types and comorbid disorders.
Construct Validity (e.g. Predictive, Concurrent, Convergent, and Discriminant Validity)
Excellent
Shows convergent validity with other symptom scales. Correlations between CMRS-P and other several clinician-rating scales intended to measure manic symptoms (e.g. Washington University Schedule for Affective Disorder and Schizophrenia mania module, the Schedule for Affective Disorders and Schizophrenia Mania Rating Scale, and the Young Mania Rating Scales) were excellent (.78 to .98).
Discriminative Validity
Excellent/Too Good
Preliminary studies show that CMRS scores discriminate cases with unipolar and bipolar mood disorders from other clinical disorders. AUCs of >.90 are quite high. Comparison to healthy controls might imply unrealistic performance when compared to realities of clinical practice.
Validity Generalisation
Adequate
Shown to be effective for ethnically representative samples. More research and multiple settings are needed to sufficiently determine generalization.
Treatment Sensitivity
Good
The CMRS-P has also been found to be sensitive in detecting symptom change over the course of treatment in multiple studies.
Clinical Utility
Excellent
Free (public domain), designed to be completed in 10-15 minutes, preliminary data are promising. Less research than some of the other contenders, but easier reading level than General Behaviour Inventory and more sensitive to treatment effects than Mood Disorder Questionnaire.
Development and History
The CMRS was developed as a shorter, reliable, and valid parent-report screening instrument for mania. The short form was derived from the CMRS 21 item scale which is the first original mania rating scale developed for children and adolescents. It was not developed from the Young Mania Rating Scale (YMRS) that was originally designed for adults, ‘Young’ being the name of the author than the fact that it was a scale for ‘young’ population. The YMRS was derived from the Parent-Young Mania Rating Scale (P-YMRS). This scale, developed from the YMRS, was created for use with adult inpatients. The items of the P-YMRS did not include the updated DSM-IV criteria for adolescent Bipolar Disorder, and it includes several items with poor factor loadings. Furthermore, the content is not developmentally appropriate for children, as many of the items require insight or appearance, which are irrelevant to young children. Another promising measure is the GBI as it has good psychometric properties. However, the GBI is lengthy and complicated and requires the child to have at least a 7th-grade reading ability. One of the most widely used measures of mania symptoms is the Kiddie Schedule for Affective Disorders and Schizophrenia mania section. However, this measure is extremely extensive and requires much clinical training to administer.
During the development of the CMRS, researchers found that reliable and more accurate diagnostic accuracy is found in parent reports in comparison to teacher reports or self-reports and that these other reports rarely added new information to the parent report. Furthermore, the areas under the curve (AUC) of parent-rated instruments reported modest to excellent validity. Based on the evidence, the developers of the CMRS chose to create a measure that relied mainly on parent report.
Other parent report measures have been used to screen for Paediatric Bipolar Disorder, but these measures were not developed to look specifically for mania. One such measure is the Child Behaviour Checklist (CBCL). The CBCL, in addition to providing markers of psychopathology, has been used to detect mania in children. However, on the CBCL, researchers saw a consistent pattern of elevated scores, especially on the following symptoms: aggressive behaviour, attention problems, delinquency, anxiety, and depression. This pattern may be due to the high comorbidity of ADHD, oppositional defiant disorder, conduct disorder, and anxiety disorders in children with paediatric Bipolar Disorder. And although the CBCL is a reliable and validated measure, low scores on the CBCL may only rule out mania – conversely, it would be erroneous to rule in mania using CBCL scores alone.
For these reasons, the CMRS was developed to accurately and reliably assess mania in paediatric Bipolar Disorder, and differentiate its symptoms from other disorders with high comorbidity with paediatric Bipolar Disorder.
Impact
Though there is no gold-standard screening tool for Paediatric Bipolar Disorder, the CMRS has been described as a promising and useful tool for such a purpose. For example, institutional protocols for diagnosing and evaluating Bipolar Disorder in children may use the CMRS as an initial screening tool to establish the need to further evaluation of mania symptoms. In addition, the parent version of the CMRS (the CMRS-P) has been used in research studies to detect changes in children’s mania symptoms due to pharmacotherapy or psychotherapy. The CMRS is the first measure specifically developed for the purpose of screening for Bipolar Disorder in children.[30] As such, it offers an alternative to broadband rating scales like the Child Behaviour Checklist, which has been used as a screening tool for Bipolar Disorder in children with mixed findings regarding its reliability.
Furthermore, the CMRS-P (both the brief and full versions) have shown to be effective in distinguishing between mania and ADHD. The brief version effectively retains characteristics of the original CMRS, allowing for wider application and longitudinal use. Psychometric studies of the CMRS has demonstrated that the measure has excellent reliability and validity. Internal consistency is excellent and the measure correlates with clinician-administered interview measures for diagnosing paediatric mania. The measure is also accurately able to differentiate symptoms of paediatric Bipolar Disorder from ADHD and healthy control groups more than 90% of the time. Furthermore, the use of the CMRS in pharmacological research suggests that this measure is sensitive to treatment over time, which means that you can use this measure to assess treatment effectiveness.
Limitations
The CMRS suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimised by the person completing them – in this case, the parent or teacher – in a phenomenon called the social desirability bias. Like all questionnaires, the way the instrument is administered can also influence the final score. If a person is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations have been shown to elicit a different response compared to administration via a postal survey. The age of the youth also may matter. Although the Child Mania Rating Scale has been shown to be a valid and reliable measure of mania in children, one concern is that its validity might change as the youth becomes an adolescent, and parents or teachers have less influence and awareness about the youth’s behaviour outside of the home or school. Additionally, it is also unclear of the CMRS’s ability to assess the change in mania systems as a child cycles out of mania and into depression.
Use in Other Populations
While the CMRS has not been validated in other languages, the CBCL, YMRS, GBI, and KSADS all have. However, the CMRS has been tested and translated into Spanish. The CMRS is available in fourteen languages with back translation through native/bilingual speakers, though not tested in all languages.
The Altman Self-Rating Mania Scale (ASRM) is a 5-item self-reported diagnostic scale which can be used to assess the presence and severity manic and hypomanic symptoms, most commonly in patients diagnosed with bipolar disorder.
Effectiveness
The ASRM scale has been shown to be an effective self-reported questionnaire for screening patients with acute mania as well as measuring anti-manic treatment effects. Though only a 5-question instrument, the scale’s compatibility with the clinician administered Young Mania Rating Scale and the DSM-IV criteria give substantial diagnostic power for such a brief instrument.
Format
The Altman Self-Rating Mania Scale assess differences in “normal” or baseline levels in five subjective and behavioural areas:
Positive mood.
Self-confidence.
Sleep patterns.
Speech patterns and amount.
Motor activity.
Each of these areas has five statements which correspond to scores 0 through 4; with 0 being unchanged from “normal” or baseline, to 4 being overtly manic thoughts or behaviour. The subject is asked to choose one statement from each of the five areas that best describes the way they have been feeling over the past week.
Scoring
Scores above a 5 are indicative of mania, or hypomania, with the severity of symptoms increasing with higher scores. Examining score changes over time is also used to determine the efficacy of a particular treatment in a clinical setting and to qualify whether the severity a manic episode is increasing or decreasing.
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