DOI: 10.5281/zenodo.17156087
title: Development of a Rating Instrument to Identify Catatonia by Virtual Viewing of Motor Assessments

description:        We initially sought to assess the feasibility of virtual motor assessments of a boy with slow movements utilizing three rating tools suitable for children with catatonia [Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)® (American Psychiatric Association, 2013) (Figure 1); Pediatric Catatonia Rating Scale (PCRS) (Benarous, et al., 2016) (Figure 2); Bush-Francis Catatonia Rating Scale (BFCRS) (Bush, et al., 1996) (Figure 3)]. On their own monitors in different locations, three investigators viewed an edited video of clinical assessments of a 16-year-old boy displayed by the coordinator. The edited video was shown to all raters together once before each rater independently completed rating of each tool. If an item could not be scored based on the clinical video, raters scored the item with an “X.” First, they rated the BFCRS (Bush, et al., 1996) (Figure 3), then the PCRS (Benarous, et al., 2016) (Figure 2), and finally, the DSM-5 (American Psychiatric Association, 2013) (Figure 1). After each scale was completed, the coordinator obtained the independent scores of all raters and conducted a consensus conference to attain agreement on the scores for each item. If the raters did not agree on a score, then the consensus score was “.” (period) to indicate lack of agreement (Kadubandi, et al., 2024, 2025).

            We then sought to conduct a comprehensive review of all rating scales for catatonia to construct an optimal scale including the crucial items from extant scales. A recent systematic review (Hirjak, et al., 2024) identified two clinical criteria (American Psychiatric Association, 2013; ICD-11 for Mortality and Morbidity Statistics, 2024) and two scales (Bush, et al., 1996; Northoff, et al., 2001) as the most widely utilized instruments so those instruments were used to construct our optimal scale. Since we aimed to rate videos of a child, we also utilized the PCRS (Benarous, et al., 2016).

            We then constructed a spreadsheet with the key criteria for each scale and each of the scales identified with a column as follows: ICD11 (ICD-11 for Mortality and Morbidity Statistics, 2024), DSM5 (American Psychiatric Association, 2013), Bush-Francis Catatonia Rating Scale (BFCRS) (Bush, et al., 1996), Northoff Catatonia Rating Scale (NCRS) (Northoff, et al., 2001), and Pediatric Catatonia Rating Scale (PCRS) (Benarous, et al., 2016) (Table 1). Because many scales included many specific items, Table 1 was expanded to include all the detailed items of the five target rating procedures (American Psychiatric Association, 2013; Benarous, et al., 2016; Bush, et al., 1996; ICD-11 for Mortality and Morbidity Statistics, 2024; Northoff, et al., 2001) (Table 2).

            We then sought to construct a checklist of behaviors that could be identified on remote viewing of a video of a prior motor assessment of a patient. Since the patient could not be interviewed to determine subjective experiences, items were limited to objective movements and utterances. Since clinical motor assessment examinations were viewed on videotapes, specific durations for assessments and repetitious actions and utterances were omitted. The goal was to construct a checklist for items to identify as present with a 1 or absent with a 0 on viewing the videotape (Table 3).

            We then sought to organize the rating form in a manner that could be readily scored by raters viewing virtual motor assessments once (Table 4). We further revised the rating form by removing (A) items that could not be readily assessed by viewing a video of a motor assessment and (B) phrases that did not convey the crucial concepts that could be recognized on recorded motor assessments in standard English (Table 5).

            Further efforts to evaluate a proposed instrument to identify catatonia were the remote testing of the novel tool by a team of trained raters utilizing a process for remote scoring of videos shown to the team of raters once by a coordinator followed by independent ratings by each rater and then a consensus conference to attain agreement by discussion by all raters (Elshourbagy, et al., 2023a,b). We utilized the dictum to rate as present only items that are unequivocably present (Oldham and Francis, 2022). We strived to use terminology commonly used in the literature (Oldham and Francis, 2022). We sought to develop a protocol without a structured interview and examination of the participant suitable for general motor assessments (Table 6).

            We recruited a team of trained raters to independently score videos of people with and without evidence of the increased, decreased, and abnormal movements characteristic of catatonia utilizing the procedure under development. We welcomed domestic and international colleagues to participate in an organizational meeting to discuss the planned rating of videos of a male. To establish skill as a trained rater, all raters completed a one-hour online course intended to teach psychiatrists and psychiatry trainees how to improve their diagnosis of catatonia using the Bush-Francis Catatonia Rating Scale (https://redcap.urmc.rochester.edu/redcap/surveys/?s=LWNL3EC78Y) and registered for the 3-month follow up. All raters independently scored the pre-module and post-module tests without checking the answers until their scores were recorded to send to the organizing committee. All raters independently scored on blank BFCRS forms the videos for hypokinetic catatonia, parakinetic catatonia, and hyperkinetic catatonia, and Patients A and B, before viewing the answers and sent their original independent score sheets to the organizing committee before viewing the answers. The scores will be evaluated for presentation and publication.

            All raters participated in an online organizational training session. This session was recorded for subsequent viewing by all raters including those who were unable to attend the online session.

            Raters were trained to use a battery of instruments that have been used to assess people with catatonia and related conditions: Abnormal Involuntary Movement Scales (AIMS) (National Institute of Mental Health, 1988), BFCRS (Bush, et al., 1996), Catatonia Quick Screen (CQS) (Luccarelli, et al., 2024), Children’s Global Assessment Scale (CGAS) (Shaffer, et al., 1983, 1985) (Figure 4), Clinical Global Impressions (CGI) (Guy, 1976), DSM-5 (American Psychiatric Association, 2013), Hillside Akathisia Scale (HAS) (Fleischhacker, et al., 1989), ICD-11 (ICD-11 for Mortality and Morbidity Statistics, 2024), Timed Stereotypies Rating Scale (TSRS) (Brasic, 2003); and the new tool under development (Table 7). The PCRS (Benarous, et al., 2016) (Table 1) was not included because the key items were already included in the battery of instruments.

           A goal of the current project is to generate a tool including only objective items. A flaw of other tools, including NCRS (Northoff, et al., 2001) and the BFCRS(Bush, et al., 1996), is the need of the examiner to identify the motivation of the patient by observation of behavior. A further goal is to organize items in related categories. Therefore, “a persisting lack of eye contact (e.g., as though dejected or may be actively avoiding eye contact),” (Oldham and Francis, 2022, page 8), a concept that requires the examiner to know the motivation of the patient, is now categorized as staring fixed gaze in the new tool (Table 7), not withdrawal (Bush, et al., 1996). This step also the removes the association of two unrelated occurrences, the failure to consume food and water and the avoidance of eye contact (Bush, et al., 1996).

          The subjective thoughts of the patient cannot be determined by an examiner by observing a motor assessment. However, to score items included in catatonia scales, raters imagined what patients were experiencing by viewing the videos of the patients.

          Another goal of the current project is to eliminate items that cannot be objectively identified by observation of a motor assessment. Since temperature, blood pressure, pulse, respiratory rate, and diaphoresis (Bush, et al., 1996) cannot be determined by observation of a recorded motor assessment, those items are not included (Table 7). To include the key features of extant scales, the new scale was revised (Table 7).

            The team of trained raters met to score videos of a male. At the beginning of each session the coordinator instructed raters to begin scoring forms (American Psychiatric Association, 2013; Bush, et al., 1996; Guy, 1976; ICD-11 for Mortality and Morbidity Statistics, 2024; Luccarelli, et al., 2024; Shaffer, et al., 1983, 1985) including the new tool under development during the video and to check their scores after the video was displayed. The coordinator advised the team that the Abnormal Involuntary Movement Scale (AIMS) (National Institute of Mental Health, 1988), the Hillside Akathisia Scale (HAS) (Fleischhacker, et al., 1987), and the Timed Stereotypies Rating Scale (TSRS) (Brasic, 2003) would be administered in the middle of the video. The coordinator advised that he would warn the team a minute or so in advance to put the blank TSRS on their instrument to begin scoring.

          Videos of sequential sessions of a male were displayed by the coordinator to be viewed independently by each trained rater. Raters were asked to complete their scoring independently without consultation with others. After the raters completed and checked their independent score sheets, they sent them to the organizing committee for tabulation. The coordinator then conducted a consensus meeting with all raters to attain agreement on the score for each item if possible.

          The raters were told only the age and sex of the patient for each session. Sessions were conducted twice weekly for three weeks. The patient was identified as a 17-year-10-month-19-day-old male for session 1, an 18-year-3-month-25-day-old male for session 2, an 18-year-3-month-25-day-old male for session 3, an 18-year-8-month-14-day-old male for session 4, an 18-year-11-month-20-day-old male for session 5, and a 19-year-11-month-1-day-old male for session 6. After the completion of session 5, raters were informed that the patient was actually a 16-year-8-month old male for session 5. The videos had mistakenly been presented out of chronological order.

          Because the key components of ICD11 (ICD-11 for Mortality and Morbidity Statistics, 2024) were included in other instruments, ICD11 was omitted after the first rating session.

          After completing the six rating sessions raters were provided the published data about the patient [Brašić, et al., 1999, 2000a,b(Figure 5), 2015]. Nomenclature (American Psychiatric Association, 2013) has changed since the orginal publications about the patient with catatonia [Brašić, et al., 1999, 2000a,b(Figure 5), 2015]. The patient fulfils criteria for autism spectrum disorder (American Psychiatric Association, 2013). Therefore, the original publications about this patient [Brašić, et al., 1999, 2000a,b(Figure 5), 2015] constitute the first reports of progressive catatonia in an individual with autism spectrum disorder that is refractory to clinical interventions for catatonia.

          After complete the six rating sessions raters were asked for suggestions to improve the process. Their suggestions are tabulated as follows:

       

 DSM-5 (American Psychiatric Association, 2013)

Confusion was noted for items in the negative as follows:

     “C.  The disturbance is not better explained by another mental disorder (e.g., a manic episode).

      “D. The disturbance does not occur exclusively during the course of a delirium.” (American Psychiatric Association, 2013, page 120)

Rewording those items in the positive may minimize confusion.

 

          BFCRS (Bush, et al., 1996)

The descriptions are not mutually exclusive in some places. Whether “Grimacing” refers to the maintenance of each individual instance of grimace or grimacing as a whole was pointed out as an item that requires clarification. Adding a section for patient history for information that was not available on the motor examination on the video was suggested. Clarification if items with multiple terms are scored if only one, but not all, of the terms are present was requested.

 

          Tool under development (Table 7)

Clarification of the item “Staring Decreased blinking” was requested. Renaming this item “Automatic blinking” was suggested. Adding “Eye closing” was suggested.

Rewording the description of catalepsy from “passive induction of posture” to “passive induction of a limb” was suggested rule out any ambiguity of the term “posture.” 

Rewording the description of an item for “Posturing” from “Maintenance of a posture including sitting or standing for long periods without reacting” to “Maintenance of abnormal posture including normal position of sitting or standing but for unusual periods of time” was suggested.

Rewording the description of an item for “Posturing Spontaneous and/or active maintenance of a posture against gravity” to specify a limb either placed in a position by someone else or by the patient themself was suggested. Differentiation from catalepsy was suggested.

Clarification if “Rigidity” is against another person’s force was suggested. 

 

          Hillside Akathisia Scale (HAS) (Fleishhacker, et al., 1989)

Since the patient did not express his experienced, scoring subjective items was not possible. Revising this section with “While restrained or with force in opposite direction of movement, does the patient seem to want to continue to move?” or “Does the patient seem no different, distressed, or relieved when movements are prevented?” was suggested.

 

          Timed Stereotypies Rating Scale (TSRS) (Brasic, 2003)

For this procedure an examiner announces the start of the administration and speaks out loud time intervals to indicate thirty-second durations of a ten-minute rating session (zero minutes zero seconds, zero minutes thirty seconds, one minute zero seconds, . . . , nine minutes thirty seconds, ten minutes). Raters then make a single check mark in the box corresponding to each stereotypy exhibited by the patient during each thirty-second duration. Reducing the time period to six minutes was suggested. Also making check marks every time a stereotypy occurred in each thirty-second interval was suggested. Adding specific nose movements (nose crinkling, nose twitching) was suggested. Distinguishing biting and chewing with mouth open or closed was suggested. Adding an item “clenching” to indicate closed teeth was recommended.

 

The project was presented at the annual meeting of the National Network of Depression Centers in Cincinnati, Ohio, USA, on September 10-11, 2025 (Figure 6).

 

When catatonia is confirmed, then referral to an organization qualified to provide appropriate interventions is appropriate. Children and adolescents with catatonia may benefit from hospitalization at a facility with the staff and resources required to manage them (Smith, et al., 2024).

 

References:

 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)®, Arlington, Virginia, USA, American Psychiatric Association, 2013, pp 119-121.

 

Benarous X, Consoli A, Raffin M, Bodeau N, Giannitelli M, Cohen D, Olliac B. Validation of the Pediatric Catatonia Rating Scale (PCRS). Schizophr Res. 2016;176:378-386.

 

Brašić JR. Treatment of movement disorders in autism spectrum disorders. In: Hollander E (Editor). Autism Spectrum Disorders. Volume 24 of the Medical Psychiatry Series. ISBN 0-8247-0715-X Marcel Dekker, Inc., New York. 2003;273-346.

 

Brašić JR, Barnett JY, Will MV, Nadrich RH, Sheitman BB, Ahmad R, Mendonça MF, Kaplan D, Brathwaite C. Dyskinesias differentiate autistic disorder from catatonia. CNS Spectr. 2000a;5(12):19-22. PubMed PMID: 17545961.

 

Brasić J, Barnett J, Zagzag D, Twenty-four-year unremitting course of facial tics in progressive catatonia complicating autism spectrum disorder. 1st World Congress on Tourette Syndrome and Tic Disorders. London, UK, June 24-26, 2015. 2015: 32-37. [abstract] Available online: https://doi.org/10.3389/978-2-88919-669-2 Accessed July 18, 2025.

 

Brašić JR, Zagzag D, Kowalik S, Prichep L, John ER, Barnett JY, Bronson B, Nadrich RH, Cancro R, Buchsbaum M, Brathwaite C. Clinical manifestations of progressive catatonia. German Journal of Psychiatry. 2000b;3(2):13-24. (Out of print) (Figure 5)

 

Brasić JR, Zagzag D, Kowalik S, Prichep L, John ER, Liang HG, Klutchko B, Cancro R, Sheitman BB, Buchsbaum M, Brathwaite C. Progressive catatonia. Psychol Rep. 1999;84(1):239-246. PubMed PMID: 10203957.

 

Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93:129-136.

 

Elshourbagy A, Eltaras MM, Abdalshafy H, Javed S, Sadaney AO, Harrigan TP, Mills KA, Hernandez ME, Brašić JR.  Feasibility of virtual low-cost quantitative continuous measurement of movements in the extremities of people with Parkinson‘s disease. MethodsX. 2023a;11:102230. https://doi.org/10.1016/j.mex.2023.102230

Corrigendum

Elshourbagy A, Eltaras MM, Abdalshafy H, Javed S, Sadaney AO, Harrigan TP, Mills KA, Hernandez ME, Brašić JR. Corrigendum to “Feasibility of virtual low-cost quantitative continuous measurement of movements in the extremities of people with Parkinson’s disease ” [MethodsX 11 (2023) 102230]. MethodsX. 2023b;11:102368. https://doi.org/10.1016/j.mex.2023.102368

 

Fleischhacker WW, Bergmann KJ, Perovich R, Pestreich CK, Borenstein M, Lieberman JA, Kane JM. The Hillside Akathisia Scale: a new rating scale for neuroleptic-induced akathisia. Psychopharmacol Bull. I989;25:222-226.

 

Guy W. ECDEU Assessment Manual for Psychopharmacology, Revised, 1976. Rockville, Maryland: United States Department of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1976. (DHEW Publication No. (ADM) 76-338)

 

Hirjak D, Brandt GA, Fritze S, Kubera KM, Northoff G, Wolf RC. Distribution and frequency of clinical criteria and rating scales for diagnosis and assessment of catatonia in different study types. Schizophr Res. 2024;263:93-98.

 

ICD-11 for Mortality and Morbidity Statistics. Catatonia. 2024. Available online: https://icd.who.int/browse/2024-01/mms/en#486722075 Accessed July 18, 2025.

 

Kadubandi N, Elshourbagy A, Brašić J. Feasibility of reliable, remote assessment of a 13-year-old boy who stopped talking [abstract]. Mov Disord. 2024; 39 (suppl 1): S735-S736. Available online: https://www.mdsabstracts.org/abstract/feasibility-of-reliable-remote-assessment-of-a-13-year-old-boy-who-stopped-talking/ Accessed May 4, 2025.

 

Kadubandi N, Elshourbagy A, Smith L, Balousha A, Tacik P, Barnett J, Brasic J. Feasibility of reliable, remote assessment of a 13-year-old boy who stopped talking. Zenodo, V10, 2025.

https://doi.org/10.5281/zenodo.15801759

 

Luccarelli J, Kalinich M, Wilson JE, Liu J, Fuchs C, Francis A, Heckers S, Fricchione G, Smith JR. The Catatonia Quick Screen (CQS): A Rapid Screening Tool for Catatonia in Adult and Pediatric Populations. medRxiv. 2024. https://doi.org/10.1101/2024.11.26.24317940

 

National Institute of Mental Health, Alcohol, Drug Abuse, and Mental Health Administration, Public Health Service, Department of Health, Education, and Welfare: Abnormal Involuntary Movement Scale (AIMS). Psychopharmacol Bull. Volume 24, Number 4, 1988, pages 781-783.

 

Northoff G, Koch K, Wenke J, Eckert J, Böker H, Pflug B, Bogerts B.Mov Disord. 1999;14(3):404-416. https://doi.org/10.1002/1531-8257(199905)14:3<404::aid-mds1004>3.0.co;2-5. PMID: 10348462

 

Oldham MA, Francis A. Bush-Francis Catatonia Rating Scale: Training Manual and Coding Guide. 2022. University of Rochester Medical Center, Rochester, New York, USA. Available at https://www.urmc.rochester.edu/psychiatry/divisions/collaborative-care-and-wellness/bush-francis-catatonia-rating-scale (accessed 20 March 2025).

 

Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, Aluwahlia S. A children’s global assessment scale (CGAS). Arch Gen Psychiatry. 1983;16(11):1228-1231. PubMed PMID: 6639293.

 

Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, Aluwahlia S. A children’s global assessment scale (CGAS) (for ages 4 to16). Psychopharm Bull. 1985;21(4):747-748. (Figure 4).

 

Smith JR, York T, Hart S, M Patel A, Kreth HL, Spencer K, Grizzle KB, Wilson JE, Pagano L, Zaim N, Fuchs C. The development of a pediatric catatonia clinical roadmap for clinical care at Vanderbilt University Medical Center. J Acad Consult Liaison Psychiatry. 2024;65(6):570-578. https://doi.org/10.1016/j.jaclp.2024.08.003.

 

 

Legends for Figures and Tables

 

Figure 1. Catatonic Disorder Due to Another Medical Condition. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)®, Arlington, Virginia, USA, American Psychiatric Association, 2013, p. 120.

 

Figure 2. The Pediatric Catatonic Rating Scale. Benarous X, Consoli A, Raffin M, et al. Validation of the Pediatric Catatonia Rating Scale (PCRS). Schizophr Res 2016; 176:385-386.

 

Figure 3. Bush-Francis Catatonia Rating Scale. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand 1996; 93:134-135.

 

Figure 4. A Children's Global Assessment Scale. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, Aluwahlia S. A children’s global assessment scale (CGAS) (for ages 4 to16). Psychopharm Bull. 1985;21(4):747-748.

 

Figure 5. Clinical manifestations fo progressive catatonia. Brašić JR, Zagzag D, Kowalik S, Prichep L, John ER, Barnett JY, Bronson B, Nadrich RH, Cancro R, Buchsbaum M, Brathwaite C. Clinical manifestations of progressive catatonia. German Journal of Psychiatry. 2000b;3(2):13-24. (Out of print)

 

Figure 6. Development of a rating instrument to identify catatonia by virtual viewing of motor assessments. Kadubandi N, Elshourbagy A, Tasmiya A, Epstein A,  Smith L, van Emde Boas M, Rezq H, Barnett J, Brasic J. Poster presented at the annual meeting of the National Network of Depression Centers in Cincinnati, Ohio, USA, on September 10-11, 2025.

 

Table 1. Representation of key criteria for catatonia in leading clinical criteria and rating scales suitable for children.

 

ICD11 (ICD-11 for Mortality and Morbidity Statistics, 2024); DSM5 American Psychiatric Association, 2013), BFCRS (Bush, et al., 1996), NCRS (Northoff, et al., 2001), PCRS (Benarous, et al., 2016).

 

Score each item as follows:

 

1 = present, 0 = absent.

 

Table 2. Representation of detailed criteria for catatonia in leading clinical criteria and rating scales suitable for children.

 

ICD11 (ICD-11 for Mortality and Morbidity Statistics, 2024); DSM5 American Psychiatric Association, 2013), BFCRS (Bush, et al., 1996), NCRS (Northoff, et al., 2001), PCRS (Benarous, et al., 2016).

 

Score each item as follows:

 

1 = present, 0 = absent, empty cell = absent.

 

Table 3. Extensive checklist of detailed criteria for catatonia suitable for remote assessments of videos of clinical motor assessments of people.

 

Score each item as follows:

1 = present, 0 = absent.

 

Table 4. Checklist of categories of criteria for catatonia suitable for remote assessments of videos of clinical motor assessments of people.

 

Score each item as follows:

1 = present, 0 = absent.

 

Table 5. Checklist to identify criteria for catatonia suitable for remote assessments of videos of clinical motor assessments of people.

 

Score each item as follows:

1 = present, 0 = absent.

 

Table 6. Checklist to identify criteria for catatonia suitable for remote assessments of videos of clinical motor assessments of people.

 

Score each item as follows:

1 = present, 0 = absent.

 

Table 7. Checklist to identify criteria for catatonia suitable for remote assessments of videos of clinical motor assessments of people.

 

Place a check on the right-hand column if the item is clearly present. Otherwise, leave the box blank.