Bush-Francis Catatonia Rating Scale (BFCRS)

Abstract

The Bush-Francis Catatonia Rating Scale (BFCRS) is a standardized, quantifiable instrument developed in 1996 for the reliable screening, diagnosis, and severity assessment of catatonia. Developed by Bush and colleagues, the scale is grounded in clinical literature and incorporates specific motor signs identified in the internationally recognized DSM-III, DSM-IV, and ICD-10 diagnostic criteria. The BFCRS is valued in clinical practice for its efficient administration time—typically around five minutes—and its robust psychometric properties, making it a preferred tool for clinicians and researchers monitoring this complex neuropsychiatric syndrome.

Keywords

Bush-Francis Catatonia Rating Scale, BFCRS, BFCSI, Catatonia, standardized examination, psychiatric assessment, motor signs, screening instrument, severity rating, psychosis.

Authors

G. Bush, M. Fink, G. Petrides, F. Dowling, A. Francis.

Purpose

The primary purpose of the BFCRS is to provide an objective, systematic method for the detection and quantification of catatonic signs in acutely ill patients. It is designed to overcome the subjectivity inherent in purely clinical observation by coupling a 23-item rating scale with a mandatory, standardized examination procedure consisting of nine specific steps.

The scale serves a critical diagnostic function through its subset, the Bush-Francis Catatonia Screening Instrument (BFCSI), which comprises the first 14 items. For screening purposes, items are marked as either absent (0) or present (3). The presence of two or more of these screening items, persisting for 24 hours or longer, is sufficient to meet the diagnosis for catatonia as proposed by the developers. The full 23-item scale is then used to accurately measure the overall severity of the catatonic syndrome.

Construct

The BFCRS measures the psychological and behavioral construct of catatonia, defined as a distinct neuropsychiatric syndrome characterized by profound abnormalities in motor activity, volition, and responsiveness to the environment. The scale operationalizes this construct into 23 observable, discrete behavioral items.

The items were synthesized from established literature and official diagnostic criteria, ensuring comprehensive coverage of the syndrome’s presentation. The structured examination procedure is crucial for eliciting key motor signs—such as **Echopraxia**, **Waxy Flexibility**, and **Automatic Obedience**—that may not be spontaneously observed, thereby ensuring that the full scope of the catatonic construct is assessed systematically.

Validity

Initial assessment of the BFCRS’s validity faced challenges due to the lack of a universally accepted, independent diagnostic standard for catatonia at the time of its creation. Despite this, the scale demonstrated robust foundational validity.

Content validity was established by comparing the 23 items against multiple existing sources and diagnostic descriptions of catatonia. This comparison showed high coverage, with 96% of the items being included in at least two independent sources (Bush et al.). Furthermore, diagnostic agreement between cases identified using the BFCSI and previously published clinical criteria for catatonia was strong, ranging from 75% to 100% (Bush et al., 1996). A subsequent translation into Portuguese confirmed that the scale maintained its validity and reliability within a different cultural and linguistic context (Santos Nunes et al., 2017).

Reliability

The BFCRS demonstrates high consistency, particularly regarding agreement among different clinicians. Both the full scale and the screening subset exhibited excellent inter-rater reliability during the initial validation studies: r = 0.93 for the BFCRS and r = 0.95 for the BFCSI. This indicates that the standardized procedures and clear scoring guidelines minimize subjective interpretation across raters.

The reliability of the scale’s measurement over time (test-retest reliability) was not studied by the original authors due to the recognized fluctuating course of the catatonic syndrome itself. Later research, however, suggested that the scale’s reliability profile may vary with symptom severity. Wilson et al. (2015) noted that the BFCRS showed low reliability when used to assess low severity levels of catatonia but maintained good reliability at moderate to severe levels. Additionally, specialized adaptations (BFCRS-0 and BFCRS-R) were later proposed as potentially more suitable for use in populations diagnosed with chronic schizophrenia (Wong et al., 2007).

Factor Analysis

While the source material does not provide data from a formal factor analysis, the structure of the BFCRS inherently separates items into two functional components. Items 1–14 constitute the core diagnostic features necessary for screening (BFCSI), suggesting a primary factor related to the presence of the syndrome. Items 15–23 contribute to the overall severity score, implying a secondary set of factors related to the quantification of symptom burden and functional impairment. Subsequent research has utilized Rasch analysis to examine the scale’s structure, particularly in populations with schizophrenia (Wong et al., 2007).

Instrument

Test Type: Observer-rated clinical scale combined with a standardized physical examination.

Format: 23-item rating scale.

Language Available: English (Original), Portuguese (Brazilian version).

Population Group: Acutely ill psychiatric patients presenting with catatonic syndrome.

Age Group: Primarily validated for adults.

Population Details: The initial validation sample included 28 acutely ill patients presenting with catatonic syndrome from an acute psychiatric inpatient clinic and a university hospital. Demographic details regarding gender were not recorded in the available published data (Wong et al., 2007).

Test Methodology: The scale requires a structured, nine-step examination procedure. For severity scoring, items 1–23 are rated using a four-point scale (0–3). The total score is the sum of all responses.

Keywords

Standardized examination, **DSM-III, IV, and ICD-10**, **inter-rater reliability**, psychiatric rating scale, **Echopraxia**, **Automatic Obedience**, affective disorders, schizophrenia.

Authors

Author ORCID Identifier: Not provided in source material.

Affiliation Email addresses: Not provided in source material.

Correspondence Address: Not provided in source material.

Permissions & Fee and Test Year

The Bush-Francis Catatonia Rating Scale and its accompanying standardized examination procedure are **freely available** for clinical and research use. The scale was first published in 1996.

The original publication can be accessed online, detailing the scale and methodology:

• Bush, G., Fink, M., Petrides, G., Dowling, F., Francis, A. (1996). Catatonia.1. Rating scale and standardized examination. **Acta Psychiatrica Scandinavica, 93**, 129-136.

Reference’s

• American Psychiatric Association. (2013). **Diagnostic and statistical manual of mental disorders** (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Bush, G., Fink, M., Petrides, G., Dowling, F., Francis, A. (1996). Catatonia.1. Rating scale and standardized examination. **Acta Psychiatrica Scandinavica, 93**, 129-136.
• Bush, G., Fink, M., Petrides, G., Dowling, F., Francis, A. (1996). Catatonia. II. Treatment with lorazepam and electroconvulsive therapy. **Acta Psychiatrica Scandinavica, 93**, 137-143.
• Santos Nunes, A. L., Filgueiras, A., Nicolato, R., Alvarenga, J. M., Silveira, A. S., Assis da Silva, R., Cheniaux, E. (2017). Development and validation of the Bush-Francis Catatonia Rating Scale – Brazilian version. **Arq Neuropsiquiatr, 75**, 44-49.
• Sienaert, P., Rooseleer, J., & De Fruyt, J. (2011). Measuring Catatatonia: A systematic review of rating scales. **Journal of Affective Disorders, 135**, 1-9. doi: 10.1016/j.jad.2011.02.012
• Tandon, R., Heckers, S., Bustillo, J., Barch, D.M., Gaebel, W., Gur, R.E., … Carpenter, W. (2013). Catatonia in DSM-5. **Schizophrenia Research, 150**, 26-30. doi: 10.1016/j.schres.2013.04.034
• Wilson, J. E., Niu, K., Nicolson, S. E., Levine, S. Z., & Heckers, S. (2015). The diagnostic criteria and structure of catatonia. **Schizophrenia Research, 164**, 256-262.
• Wong, E., Ungvari, G.S., Leung, S.K., Tang, W.K. (2007). Rating Catatonia in patients with chronic schizophrenia: Rash analysis of the Bush-Francis Catatonia Rating Scale. **International Journal of Methods in Psychiatric Research, 16**, 161-170. doi: 10.1002/mpr.224

Items of the Bush-Francis Catatonia Rating Scale (BFCRS)

The BFCRS is a 23-item rating scale. The first 14 items constitute the Bush Francis Catatonia Screening Instrument (BFCSI).

Scoring and Diagnosis:

• For screening, items 1–14 are marked as absent (0) or present (3). The presence of two or more of the screening items for 24 hours or longer meets the diagnosis for catatonia proposed by Bush et al.
• For severity, items 1–23 are rated using a scale of 0–3. The total BFCRS score is the sum of responses to all 23 items.

The rating scale is accompanied by a standardized examination procedure consisting of nine steps, designed to elicit key signs. Sample procedures include:

• To assess for **Echopraxia**, the examiner scratches his head in an exaggerated way.
• To assess for **Automatic Obedience**, the examiner reaches into his pocket and states, ‘Stick out your tongue. I want to stick a pin in it.” (Bush et al., 1996)