What is the Bush-Francis Catatonia Rating Scale?

Bush-Francis Catatonia Rating Scale

The Bush-Francis Catatonia Rating Scale (BFCRS) is a 23-item clinician-administered instrument consisting of a 14-item screening tool and a 9-item severity scale, designed to systematically identify and quantify catatonic signs and symptoms in psychiatric and neurological patients. 1

Scale Structure and Administration

The BFCRS has two components that work sequentially:

Screening Instrument (14 items)

• The first 14 items serve as a rapid screening tool to identify potential catatonia 1
• If 2 or more items are present on the screening section, the full 23-item scale should be administered 1
• This two-stage approach makes the scale efficient for routine clinical use 1

Severity Rating Scale (23 items total)

• The complete scale includes all 23 items when catatonia is suspected 1
• Each item is scored from 0 (absent) to 3 (severe) 2
• Specific definitions are provided for each severity level for every item 3
• Administration requires at most 45 minutes 3

Psychometric Properties

The BFCRS demonstrates excellent reliability and validity across diverse clinical populations:

• Inter-rater reliability is exceptionally high with Pearson correlation coefficients ranging from 0.91 to 0.99 and intraclass correlation coefficients from 0.94 to 0.99 3
• Internal consistency is very good with Cronbach's alpha of 0.89 3
• The scale has been validated in both psychiatric and neurological patient populations 4

Clinical Features Assessed

The BFCRS evaluates the core psychomotor disturbances of catatonia 5:

• Motor signs: stupor, catalepsy, waxy flexibility, posturing, mannerisms, stereotypies, psychomotor agitation 5
• Speech abnormalities: mutism, echolalia 5
• Behavioral features: negativism, grimacing, echopraxia 5

Diagnostic Threshold

• The presence of 2 or more catatonic signs on the screening instrument warrants further evaluation with the complete scale 1
• This threshold aligns with modern diagnostic approaches while maintaining sensitivity 6

Advantages Over Other Scales

The BFCRS is considered the most practical scale for routine clinical use because:

• It includes both a rapid screening tool and comprehensive assessment in one instrument 1
• Videographic resources are available to standardize administration 6
• The scale is well-founded, reliable, and easy to administer compared to alternatives like the Northoff Catatonia Rating Scale (NCRS) or Braunig Catatonia Scale (BCRS) 1
• It can be converted to DSM-5 diagnostic criteria with limited modification 6

Modified Versions

A revised version (BFCRS-R) has been developed specifically for chronic schizophrenia patients 2:

• Reduced to 20 items by removing three misfit items 2
• Uses simplified binary scoring (absent versus present) rather than 0-3 scale 2
• Shows improved psychometric properties with better item-subject matching 2
• However, the original 23-item version remains standard for general clinical use 1

Clinical Applications

The BFCRS effectively identifies catatonia across multiple conditions 4:

• Schizophrenia and mood disorders 4
• Neurodevelopmental disorders 4
• Medical conditions including encephalitis, cerebrovascular disease 4
• Postpartum psychosis, obsessive-compulsive disorder, delirium 4
• Functional neurological symptom disorder 4

Comparison with Diagnostic Criteria

• The BFCRS and KANNER scales identify the same patients as having catatonia 4
• Relying solely on DSM-5 criteria may miss some patients with catatonia that standardized scales would detect 4
• The scale provides more granular assessment than categorical diagnostic criteria, which lack specific item thresholds 6

Clinical Significance

Using the BFCRS improves detection of a potentially life-threatening but reversible syndrome:

• Catatonia is widely under-detected in clinical practice 6
• Early identification prevents severe complications including urinary tract infections and life-threatening medical emergencies 4
• Standardized assessment with the BFCRS enhances management of morbidity and mortality 4