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Bush-Francis Catatonia Rating Scale Assessment Resources

Catatonia can be challenging to assess for a variety of reasons, but perhaps the most pressing reason of all is that comprehensive educational materials on catatonia assessment simply have not existed. We at the University of Rochester Medical Center have partnered with Andrew Francis, PhD, MD, the senior author of the Bush-Francis Catatonia Rating Scale (BFCRS), to address this need by developing the online training module below, which includes:

  • BFCRS Training Manual and Coding Guide, which reviews how to use and score the BFCRS, describes each item in detail, and explains how to differentiate items that closely resemble one another.
  • An introductory video overviewing the training videos that follow.
  • A training video depicting a standardized patient without catatonia that illustrates how to assess for all items on the BFCRS.
  • Three videos depicting standardized patients displaying three presentations of catatonia based on motoric subtype. For each, we provide a completed BFCRS for how we score these exams as well as key points from each video for reference.
  • Coming early 2022: brief point-of-care videos illustrating individual items on the BFCRS and how to score severity.
  • Test materials including two test patients and two forms of a multiple-choice test, each with an answer key.



Joshua Wortzel, MD, MPhil
Resident Physician in Psychiatry, PGY-4

Mark Oldham, MD
Assistant Professor of Psychiatry
University of Rochester
Department of Psychiatry

Clinical assessment for the Bush-Francis Catatonia Rating Scale


Normal Exam

Example of Hypokinetic Catatonia


Blank BFCRS , for scoring
BFCRS completed for this patient: Mr. Jones

Review of Key Points 

Withdrawal: Refusal to eat, drink or make eye contact

  • Includes active avoidance of eye contact
  • Differs from staring, which describes a fixed gaze
  • Rule out immobility as a cause of fasting (e.g., can test by trying to feed patient)

Immobility/Stupor: Extreme hypoactivity, unresponsiveness but not against gravity

  • Typically involves the whole body
  • Differs from posturing/catalepsy, which involves positions maintained against gravity 
  • Differs from rigidity, which describes increased muscle tone on exam

Grimacing: Odd facial expressions, including movements

  • Can affect any part of face (e.g., forehead, nose, lips, tongue)

Mutism: Verbally minimally responsive

  • Includes unintelligible whispering
  • Excludes intelligible whispering, which is manneristic speech
  • Excludes mutism due to known neurological condition (e.g., stroke)

Negativism: Motiveless resistance to instruction

  • Includes doing the opposite of instructions (e.g., opens eyes when asked to close them)
  • Do NOT score when a patient fails to stop another catatonic feature on command (e.g., immobile patient does not sit up when asked to)

Gegenhalten: Muscle resistance proportional to the force applied

  • Differs from rigidity, which is consistent, increased muscle tone throughout the range of motion

Rigidity: Increased muscle tone throughout movement

  • Differs from waxy flexibility, which is initially increased muscle tone that quickly releases
  • Differs from immobility/stupor, which refers to lack of movement rather than increase in muscle tone

Stereotypy: Repetitive, non-goal-directed movement

  • Abnormal by virtue of excessive repetition, not in the movement itself
  • Differs from mannerism, which is bizarre but purposeful (e.g., walking like a chicken) 

Example of Parakinetic Catatonia

BFCRS forms

Blank BFCRS , for scoring
BFCRS completed for this patient: Mr. Smith

Review of Key Points 

Posturing: Spontaneous maintenance of a position against gravity

  • Differs from catalepsy, which is maintaining a position induced by the examiner
  • Differs from immobility, which describes diminished activity of the whole body

Staring: Fixed gaze, no scanning of room

  • Differs from withdrawal, which is specifically avoiding eye contact with others

Immobility: Extreme hypoactivity/lack of movement

  • Differs from rigidity, which is increased muscle tone
  • Differs from posturing/catalepsy, which involves positions held against gravity

Manneristic Speech: Odd but purposeful speech

  • Abnormal inflections, accents, or tone that differ from patient’s regular speech

Verbal Perseveration: Repeating the same word or phrase or returning to the same topic

  • Differs from verbigeration, which sounds like a skipping record

Catalepsy: Maintaining a position induced by the examiner

  • Differs from posturing, which is maintaining a position assumed spontaneously

Waxy Flexibility: Initial resistance to movement that quickly releases

  • Differs from gegenhalten, which is resistance proportional to the force applied
  • Note: DSM-5 defines waxy flexibility differently, as “slight, even” resistance during repositioning; slight, even resistance is scored as rigidity on the BFCRS

Mitgehen: Patient’s arm rises with light pressure despite instruction to resist

Impulsivity: Sudden inappropriate behavior

  • Differs from combativeness, which describes an impulsive, purposeless act to harm another person
  • Differs from excitement, which emphasizes the frequency or constancy of overall activity 

Example of Hyperkinetic Catatonia


Blank BFCRS , for scoring
BFCRS completed for this patient: Mr. Adams

Review of Key Points 

Excitement: Constant motor movements that are apparently purposeless

  • Excludes akathisia

Ambitendency: Motorically indecisive, “stuck” movements

  • Can present as either complete stoppage of movement or vacillating behaviors (e.g., stepping back and forth, in and out of a doorway)

Automatic Obedience: Exaggerated cooperation, even if the stimulus is aversive to patient

Perseveration: Difficulty shifting topics or stopping movements

  • Motor perseveration differs from stereotypy and mannerisms, both of which are initiated by the patient
  • Verbal perseveration differs from verbigeration, which sounds like a skipping record

Echopraxia: Mimicking examiner’s movements

  • Can be spontaneous or elicited by examiner’s making exaggerated movements (e.g., scratching head or turning in a circle)

Verbigeration: Repetition of a phrase or sentence 

  • Sounds like a skipping record

Echolalia: Mimicking examiner’s speech

  • Mimicry is spontaneous, serves no apparent purpose, and appears automatic

Combativeness: Unprovoked, non-goal-directed aggression toward a person

  • Excludes actions that are purposeful or done in retaliation
  • Differs from impulsivity, which does not involve a potentially dangerous action done toward another person


Point-of-care Videos

  • Coming early 2022

Test Materials

Multiple Choice Test Form A
Answer Key to Multiple Choice Test Form A
Standardized Test Patient A

Multiple Choice Test Form B
Answer Key to Multiple Choice Test Form B
Standardized Test Patient B

Additional Resources

Catatonia Information Center 
Directed by Andrew Francis, PhD, MD