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URochester Medicine / Psychiatry / Our Divisions / Collaborative Care and Wellness / Bush-Francis Catatonia Rating Scale / Educational Modules

BFCRS Educational Modules

The four standardized patient training videos below illustrate a full clinical assessment for the BFCRS. The first video depicts a patient without catatonia, followed by three videos assessing a patient portraying the three common motoric catatonia subtypes.

Overview of Catatonia Assessment Resources

Dr. Oldham and Dr. Wortzel provide a brief introduction to the assessment resources available on this webpage.  

 

Standardized Patient Training Videos

Normal Exam

This video features a standardized patient without catatonia to illustrate how to assess for all items on the BFCRS.

The BFCRS Clinical Assessment can be found on pages 28-31 in the BFCRS Training Manual & Coding Guide,  which includes descriptions of the assessment and a blank BFCRS form for scoring. 

 

Examples of Catatonia

The subsequent three videos depict assessments of a standardized patient portraying catatonia's three common motoric subtypes. For each video, we provide a completed BFCRS form for how we score these assessments, along with key points for reference. 

Hypokinetic Catatonia

This video depicts an assessment of a standardized patient portraying catatonia's hypokinetic motoric subtype. 

Expand the sections below to view the answer key and key points. 

Hypokinetic Catatonia - Patient: Mr. Jones (Hypokinetic)

Download a blank BFCRS form for scoring

BFCRS Item
Item Description
Correct Answer

1. Excitement:

Extreme hyperactivity, constant motor unrest which is apparently non-purposeful. Not to be attributed to akathisia or goal-directed agitation.

0 = Absent
2. Immobility/ Stupor


Extreme hypoactivity, immobile, minimally responsive to stimuli
2 = Virtually no interaction with external world. (moaning to nailbed pressure)
3. Mutism:

Verbally unresponsive or minimally responsive
3 = No speech
4. Staring:
Fixed gaze, little or no visual scanning of environment, decreased blinking.
0 = Absent
5. Posturing/ Catalepsy:

Spontaneous maintenance of posture(s), including mundane (e.g., sitting/standing for long periodswithout reacting).
0 = Absent
6. Grimacing:

Maintenance of odd facial expressions.
3 = Bizarre expression(s) or maintained more than 1 min.
7. Echopraxia/ Echolalia:

Mimicking of examiner's movements/ speech.
0 = Absent
8. Stereotypy:

Repetitive, non-goal-directed motor activity (e.g. finger-play; repeatedly touching, patting or rubbing self);abnormality not inherent in act but in its frequency.
1 = Occasional
9. Mannerisms:

Odd, purposeful movements (hopping or walking tiptoe, saluting passersby or exaggerated caricaturesof mundane movements); abnormality inherent in act itself.
0 = Absent
10. Verbigeration:

Repetition of phrases or sentences (like a scratched record).
0 = Absent
11. Rigidity
Maintenance of a rigid position despite efforts to be moved, exclude if cog-wheeling or tremor present
3 = Severe, cannot be repostured. (scored based on the most severe joints: ankles)
12. Negativism
Apparently motiveless resistance to instructions or attempts to move/examine patient. Contrary behavior, does exact opposite of instruction.
3 = Severe resistance and/or continually contrary
13. Waxy Flexibility
During reposturing of patient, patient offers initial resistance before allowing himself to be repositioned,similar to that of a bending candle
0 = Absent
14. Withdrawal
Refusal to eat, drink and/or make eye contact
3 = No PO intake/interaction for one day or more. (specified in the video)
15. Impulsivity
Patient suddenly engages in inappropriate behavior (e.g. runs down hallway, starts screaming or takesoff clothes) without provocation. Afterwards can give no, or only a facile explanation.
0 = Absent
16. Automatic Obedience
Exaggerated cooperation with examiner's request or spontaneous continuation of movement requested.
0 = Absent
17. Mitgehen
"Anglepoise lamp" arm raising in response to light pressure of finger, despite instructions to the contrary.
0 = Absent
18. Gegenhalten
Resistance to passive movement which is proportional to strength of the stimulus, appears automaticrather than wilful.
3 = Present
19. Ambitendency
Patient appears motorically "stuck" in indecisive, hesitant movement
0 = Absent
20. Grasp Reflex
Per neurological exam.
0 = Absent
21. Perseveration
Repeatedly returns to same topic or persists with movement
0 = Absent
22. Combativeness
Usually in an undirected manner, with no, or only a facile explanation afterwards
0 = Absent
23. Autonomic Abnormality
Circle: temperature, BP, pulse, respiratory rate, diaphoresis.
0 = Absent



BFCRS Item
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)


 
 

Parakinetic Catatonia

This video depicts an assessment of a standardized patient portraying catatonia's parakinetic motoric subtype. 

Expand the sections below to view the answer key and key points. 

Parakinetic Catatonia - Patient: Mr. Smith (Parakinteitc)

Download a blank BFCRS form for scoring

BFCRS Item
Item Description
Correct Answer

1. Excitement:

Extreme hyperactivity, constant motor unrest which is apparently non-purposeful. Not to be attributed to akathisia or goal-directed agitation.

0 = Absent
2. Immobility/ Stupor


Extreme hypoactivity, immobile, minimally responsive to stimuli
1 = Sits abnormally still, may interact briefly
3. Mutism:

Verbally unresponsive or minimally responsive
0 = Absent
4. Staring:
Fixed gaze, little or no visual scanning of environment, decreased blinking.
3 = Fixed gaze, non-reactive
5. Posturing/ Catalepsy:

Spontaneous maintenance of posture(s), including mundane (e.g., sitting/standing for long periodswithout reacting).
2 = Greater than one minute, less than 15 minutes. (We see both posturing and catalepsy)
6. Grimacing:

Maintenance of odd facial expressions.
0 = Absent
7. Echopraxia/ Echolalia:

Mimicking of examiner's movements/ speech.
0 = Absent
8. Stereotypy:

Repetitive, non-goal-directed motor activity (e.g. finger-play; repeatedly touching, patting or rubbing self);abnormality not inherent in act but in its frequency.
0 = Absent
9. Mannerisms:

Odd, purposeful movements (hopping or walking tiptoe, saluting passersby or exaggerated caricaturesof mundane movements); abnormality inherent in act itself.
3 = Constant (every verbal response was robotic)
10. Verbigeration:

Repetition of phrases or sentences (like a scratched record).
0 = Absent
11. Rigidity
Maintenance of a rigid position despite efforts to be moved, exclude if cog-wheeling or tremor present
0 = Absent
12. Negativism
Apparently motiveless resistance to instructions or attempts to move/examine patient. Contrary behavior, does exact opposite of instruction.
0 = Absent
13. Waxy Flexibility
During reposturing of patient, patient offers initial resistance before allowing himself to be repositioned,similar to that of a bending candle
3 = Present
14. Withdrawal
Refusal to eat, drink and/or make eye contact
0 = Absent (We do not have information about this in the video).
15. Impulsivity
Patient suddenly engages in inappropriate behavior (e.g. runs down hallway, starts screaming or takesoff clothes) without provocation. Afterwards can give no, or only a facile explanation.
1 = Occasional
16. Automatic Obedience
Exaggerated cooperation with examiner's request or spontaneous continuation of movement requested.
0 = Absent
17. Mitgehen
"Anglepoise lamp" arm raising in response to light pressure of finger, despite instructions to the contrary.
3 = Present
18. Gegenhalten
Resistance to passive movement which is proportional to strength of the stimulus, appears automaticrather than wilful.
0 = Absent
19. Ambitendency
Patient appears motorically "stuck" in indecisive, hesitant movement
0 = Absent
20. Grasp Reflex
Per neurological exam.
0 = Absent
21. Perseveration
Repeatedly returns to same topic or persists with movement
3 = Present
22. Combativeness
Usually in an undirected manner, with no, or only a facile explanation afterwards
0 = Absent
23. Autonomic Abnormality
Circle: temperature, BP, pulse, respiratory rate, diaphoresis.
0 = Absent (not explicitly stated in the video)



BFCRS ItemKey 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 toresist 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 


 
 

Hyperkinetic Catatonia

This video depicts an assessment of a standardized patient portraying catatonia's hyperkinetic motoric subtype. 

Expand the sections below to view the answer key and key points. 

Hyperkinetic Catatonia - Patient: Mr. Adams (Hyperkinetic)

Download a blank BFCRS form for scoring

BFCRS ItemItem DescriptionCorrect Answer

1. Excitement:

Extreme hyperactivity, constant motor unrest which is apparently non-purposeful. Not to be attributed to akathisia or goal-directed agitation.

2 = Constant motion, hyperkinetic without rest periods.
2. Immobility/ StuporExtreme hypoactivity, immobile, minimally responsive to stimuli0 = Absent
3. Mutism:Verbally unresponsive or minimally responsive0 = Absent
4. Staring:Fixed gaze, little or no visual scanning of environment, decreased blinking.0 = Absent
5. Posturing/ Catalepsy:Spontaneous maintenance of posture(s), including mundane (e.g., sitting/standing for long periodswithout reacting).0 = Absent
6. Grimacing:Maintenance of odd facial expressions.0 = Absent
7. Echopraxia/ Echolalia:Mimicking of examiner's movements/ speech.2 = Frequent. (both echopraxia and echolalia)
8. Stereotypy:

Repetitive, non-goal-directed motor activity (e.g. finger-play; repeatedly touching, patting or rubbing self);abnormality not inherent in act but in its frequency.0 = Absent
9. Mannerisms:

Odd, purposeful movements (hopping or walking tiptoe, saluting passersby or exaggerated caricaturesof mundane movements); abnormality inherent in act itself.0 = Absent
10. Verbigeration:

Repetition of phrases or sentences (like a scratched record).1 = Occasional
11. Rigidity
Maintenance of a rigid position despite efforts to be moved, exclude if cog-wheeling or tremor present0 = Absent
12. NegativismApparently motiveless resistance to instructions or attempts to move/examine patient. Contrary behavior, does exact opposite of instruction.0 = Absent
13. Waxy FlexibilityDuring reposturing of patient, patient offers initial resistance before allowing himself to be repositioned,similar to that of a bending candle0 = Absent
14. WithdrawalRefusal to eat, drink and/or make eye contact0 = Absent
15. ImpulsivityPatient suddenly engages in inappropriate behavior (e.g. runs down hallway, starts screaming or takesoff clothes) without provocation. Afterwards can give no, or only a facile explanation.0 = Absent
16. Automatic ObedienceExaggerated cooperation with examiner's request or spontaneous continuation of movement requested.2 = Frequent
17. Mitgehen"Anglepoise lamp" arm raising in response to light pressure of finger, despite instructions to the contrary.0 = Absent
18. GegenhaltenResistance to passive movement which is proportional to strength of the stimulus, appears automaticrather than wilful.0 = Absent
19. AmbitendencyPatient appears motorically "stuck" in indecisive, hesitant movement3 = Present
20. Grasp ReflexPer neurological exam.0 = Absent
21. PerseverationRepeatedly returns to same topic or persists with movement3 = Present
22. CombativenessUsually in an undirected manner, with no, or only a facile explanation afterwards1 = Occasionally strikes out, low potential for injury
23. Autonomic AbnormalityCircle: temperature, BP, pulse, respiratory rate, diaphoresis.0 = Absent (not explicitly discussed in the video)


BFCRS ItemKey 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
  • Automatic obedience can involve apparently reflexive obedience to instructions that may involve an aversive stimulus or eager compliance, as shown in the video.
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 actiondone toward another person


 
 

Test materials

Below are videos of test patients A & B and corresponding forms A & B of a multiple-choice test, each with an answer key. You can also access the full 1-hour educational course as it was originally presented, with pre-, post-, and 3-month assessments.

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Standardized Test Patient A

Complete the online multiple choice test form A

 

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Standardized Test Patient B

Complete the online multiple choice test form B