Bush-Francis Catatonia Rating Scale

The Bush-Francis Catatonia Rating Scale is a specialized tool that helps doctors identify and measure the severity of catatonia, a complex condition involving unusual movements and behaviors that affects about 10% of psychiatric patients but often goes undiagnosed.

Table of contents

• What Is the Bush-Francis Catatonia Rating Scale
• How the Scale Works
• Screening Version of the Scale
• Symptoms Measured by the Scale
• Reliability and Effectiveness
• Clinical Use and Training

What Is the Bush-Francis Catatonia Rating Scale

The Bush-Francis Catatonia Rating Scale, also known as BFCRS, is a medical assessment tool used to detect and measure catatonia, which is a condition characterized by unusual motor and behavioral disturbances in patients. Catatonia is a complex problem affecting the nervous system and mental health that can occur with primary psychiatric disorders or as a result of other general medical conditions.^[3]

Published in 1996, the BFCRS has become the most widely used scale to assess catatonia in both clinical and research settings.^[14] The scale is considered an excellent tool to measure the severity of various symptoms of catatonia and has emerged as the gold standard when compared to other assessment scales.^[5]

Catatonia is often neglected when screening and examining psychiatric patients, despite affecting approximately 5% to 10% of acute psychiatric inpatients.^[14] Undiagnosed catatonia can increase illness and death rates, which demonstrates the need to effectively screen patients for the presence of catatonia as well as their response to treatment.^[3]

How the Scale Works

The Bush-Francis Catatonia Rating Scale consists of 23 items in total that assess different symptoms and behaviors associated with catatonia.^[10] Each item on the scale is scored based on severity, typically using a point system where 0 indicates the symptom is absent and higher numbers (usually 1, 2, or 3) indicate increasing severity of the symptom.^[1]

The scale includes a fixed examination procedure that helps doctors systematically assess patients for signs of catatonia.^[5] This structured approach ensures that healthcare providers examine patients consistently and thoroughly for the various features of this condition.

Educational resources have been developed to help doctors and other healthcare professionals learn how to properly use the BFCRS. These include training manuals, coding guides, and video demonstrations that show how to assess for catatonia and score individual items on the scale.^[8]

Screening Version of the Scale

A shortened version of the Bush-Francis Catatonia Rating Scale exists specifically for screening purposes, called the Bush Francis Catatonia Screening Instrument or BFCSI. This abbreviated version uses only the first 14 items from the full scale and simply scores whether each symptom is present or absent, rather than rating severity.^[5]

When using the screening version, a result is considered positive for catatonia if two or more symptoms have been present for 24 hours.^[5] This makes the screening instrument a quick and practical tool for identifying patients who may have catatonia and need further evaluation.

Studies have shown that the BFCSI is a reliable and valid screening tool for catatonia, with high pick-up rates when used to screen new hospital admissions.^[10] The screening instrument helps select patients who may have catatonia, though the final diagnosis is still made based on the complete clinical picture.^[5]

Symptoms Measured by the Scale

The Bush-Francis Catatonia Rating Scale evaluates 23 different signs and symptoms of catatonia. The first 14 items are used for screening, while all 23 items are used when measuring the full severity of the condition.^[1]

Some of the key symptoms assessed include excitement, which is extreme overactivity and constant motor restlessness that appears to have no purpose. The opposite symptom, immobility or stupor, involves extreme underactivity where the person is immobile and minimally responsive to outside stimulation.^[1]

Mutism refers to being verbally unresponsive or only minimally responsive, ranging from speaking very few words to complete absence of speech. Staring involves a fixed gaze with little or no visual scanning of the environment and decreased blinking.^[1]

The scale also measures posturing or catalepsy, which is the spontaneous maintenance of unusual body positions for long periods without reacting. Grimacing refers to maintaining odd facial expressions. Echopraxia and echolalia involve mimicking the examiner’s movements or speech.^[1]

Other symptoms include stereotypy, which is repetitive, non-goal-directed motor activity such as finger-play or repeatedly touching or patting oneself. Mannerisms are odd, purposeful movements like hopping, walking on tiptoes, or exaggerated versions of normal movements.^[1]

Verbigeration is the repetition of phrases or sentences, like a scratched record. Rigidity involves maintaining a rigid body position despite efforts to move the person. Negativism is apparently motiveless resistance to instructions or attempts to move or examine the patient, or doing the exact opposite of what is asked.^[1]

Waxy flexibility occurs during repositioning when the patient offers initial resistance before allowing themselves to be repositioned, similar to bending a candle. Withdrawal refers to refusal to eat, drink, or make eye contact. Impulsivity is when a patient suddenly engages in inappropriate behavior without provocation.^[1]

Reliability and Effectiveness

Research studies have examined how reliably different healthcare professionals can use the Bush-Francis Catatonia Rating Scale and arrive at similar conclusions. In one study with five assessors, the complete 23-item BFCRS showed the greatest level of agreement between raters, with very good reliability scores.^[10]

The study also found high correlation between the BFCRS and the BFCSI screening version, indicating that both tools work well together for identifying and measuring catatonia.^[10] These findings support the use of the Bush-Francis scales as acceptable assessment tools with good reliability when properly applied.

However, research has also revealed that many healthcare professionals, including psychiatrists, psychiatry trainees, and medical students, have gaps in their understanding of catatonia’s features. In one study with 482 participants from more than 150 medical institutions globally, participants correctly identified only about 69% of items when scoring patient videos and 55% of multiple-choice items about catatonia.^[14]

This widespread lack of understanding about the clinical diversity of catatonia may be a major reason why catatonia so often goes undiagnosed in practice, with studies finding that roughly only 1 in 10 cases of catatonia is recognized by psychiatric treatment teams.^[14]

Clinical Use and Training

The Bush-Francis Catatonia Rating Scale can be used in various clinical settings, including during in-person examinations and even through telemedicine when video technology is available. The scale has been successfully used to diagnose and treat catatonia in patients when healthcare providers are not physically in the same location as the patient.^[9]

Training materials have been developed to improve healthcare professionals’ ability to use the BFCRS effectively. These include detailed training manuals and coding guides that describe how to use the scale and explain each item in detail. Educational modules with standardized patient videos and test questions help clinicians learn to recognize the different presentations of catatonia.^[8]

The training videos illustrate three common motor subtypes of catatonia: hypokinetic catatonia (too little movement), hyperkinetic catatonia (too much movement), and parakinetic catatonia (abnormal movements). Each video comes with completed BFCRS forms showing how the assessment should be scored and key points for reference.^[8]

Video-based online educational modules have been shown to improve clinicians’ ability to identify features of catatonia. Research indicates that such training can help address the prevalent gaps in understanding catatonia’s clinical presentation among healthcare professionals at all levels of training.^[14]