Negative Symptom Initiative

Working draft of the Negative Symptom Rating Scale - 2/27/2006

MATRICS has developed a process for developing an improved instrument for measuring negative symptoms. The Work Group is chaired by Brian Kirkpatrick and includes Larry Alphs, Racquel Gur, Philip Harvey, Ann Kring, Jack Blanchard, Georges Gharabawi, William Horan, Dolores Malaspina, and Milton Strauss. A Steering Committee for the process includes William T. Carpenter, Wayne Fenton, John Kane, Stephen Marder, and Nina Schooler.

The Work Group would be grateful for comments on this draft instrument. Comments can be sent to Malina.Revett@va.gov

Introduction to the Anhedonia, Asociality, and Avolition Subscales

Introduction to the Blunted Affect and Alogia Subscales
1. Blunted Affect Subscale
2. Alogia Subscale

Overview

This rating instrument is designed to measure the current level of severity of negative symptoms in schizophrenia. Our focus in the development of this instrument was to carefully index current severity in a reliable and portable manner, without attempting to measure aspects of the subject's historical level of impairment in these areas. The instrument was designed to for use in treatment trials, but other uses are possible.

Five subscales are included: alogia, blunted affect, anhedonia, avolition, and asociality. This is a narrower definition of negative symptoms than some previous ones. For instance, there are no questions regarding cognitive changes.

All ratings are based on a semistructured interview with a structured series of prompts and queries. Ratings are generated on a 7-point (0-6) scale with anchor points ranging from 0 (absent) to 6 (severe deficit). The items are scored on the basis of the subject's current report and observation during the interview, and on the basis of other information when available.

There is no attempt to define a negative symptoms subtype or syndrome in this scale; the items do not contribute to any categorical classification scheme. While the rater should make an attempt to provide information regarding other possible influences on negative symptoms ratings, these ratings should not be adjusted on the basis of inferences regarding the origin of the symptoms (primary vs. a function of other aspects of the illness and its treatment).

Introduction to the Anhedonia, Asociality, and Avolition Subscales

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As with this rating scale in general, we are interested in assessing the current state of a subject on these different domains. As noted in the general introduction to the rating scale, we want to avoid both inferential ratings and ratings that are based on the entire lifetime or illness history of the subject. An additional point of importance is consideration of behavior observed on the part of the subject. While many of the ratings in this section of the scale require self-report, with its inherent limitations, observations of the subject's behavior and objective evidence should be given considerable weight when generating these ratings.

It is a particular challenge to rate the current state of intrinsically time-linked activities such as asociality or avolition. While information from the subject's history may be important, the task for the rater in this domain is to identify the level of current functioning, defined as the past two weeks. In so doing, it will be important to separate the current impact of prior events. Further, if a behavior has been relatively unchanging over time prior to the assessment and the subject notes that "things are different" in the immediate past, this information should be given considerable weight in the ratings.

Throughout this rating scale, another critical task of the rater is to avoid having the severity of abnormalities in one domain influence ratings in another. For instance, pleasure attained from social interactions should be considered in the anhedonia area and initiation and persistence in social activities should be considered in the avolition section.

I. Anhedonia

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Scale description:

This subscale measures two distinct aspects of the experience of pleasant emotions: Consummatory pleasure and Anticipatory pleasure.

Consummatory pleasure refers to the experience of pleasant emotions within the contexts of 1) social interactions, 2) physical sensations, and 3) recreational/vocational activities over the past two weeks. Ratings focus on the capacity to experience "in-the-moment" pleasure - I.e., the degree and extent to which the subject experienced pleasant emotions while engaged in relevant activities in these domains. For each of the three domains, two aspects of pleasurable experience are rated: intensity and frequency.

Intensity ratings refer to the peak magnitude of the subject's experience(s) of pleasant emotions, ranging from complete neutrality or indifference to highly intense experiences of pleasure.
Frequency ratings refer to the number of times the subject experienced pleasant emotions of any intensity, ranging from a complete absence of pleasant emotional experiences to experiencing pleasant emotions multiple times per day throughout the past two weeks.

Anticipatory pleasure refers to the experience of pleasant emotions while anticipating, imagining, or "looking forward to" future events in the parallel domains of social interactions, physical sensations, and recreational/vocational activities. Ratings are based on the subject's description of his/her subjective experience of pleasant emotions while considering forthcoming or possible events at the time of the interview. For each domain, one aspect of anticipatory pleasure is rated: intensity. Intensity ratings refer to the peak magnitude of the subject's experience of pleasant emotions while considering planned or possible future events, ranging from complete neutrality or indifference to a highly intense experience of pleasure.

Experience of pleasure during social interactions
Suggested questions

Have you been spending time with anyone this past month?

If Yes: Who did you spend time with? What did you do? How did you feel when you were with him/her? How often did you enjoy spending time with them?

Have you been in touch with any friends over the past two weeks?

If Yes: Who did you spend time with? What did you do? Did you enjoy your time together? How often did you enjoy time with friends?

Have you been in touch with anyone from your family?

If Yes: Who were you in touch with? Have you enjoyed spending time with your family? How often did you enjoy spending time with them?

Have you been involved in a romantic relationship?

If Yes: How have things been going in your relationship? Is there anything that you have enjoyed in your relationship? How often did you enjoy spending time with them? If No: Have you been dating? If Yes: How has it been going? Were any of the dates enjoyable? How much did you enjoy it? How often did you enjoy them?

Are there any other people you've been in contact with? Were any of your interactions with other people fun or pleasant?

If Yes: What did you enjoy? What did you feel like during the interactions? How often did you enjoy them?

Item 1: Intensity of the experience of pleasure during social interactions

Highly intense experience(s) of pleasure. The experience(s) was/were delightful or deeply satisfying ("amazing").
Strong experience(s) of pleasure. The experience(s) was/were very satisfying and fulfilling ("great", "wonderful", "fun").
Fairly strong experience(s) of pleasure ("really good", "enjoyable").
Moderate experience(s) of pleasure ("good").
Mild experience(s) of pleasure (e.g., "nice" or "OK").
Fleeting or momentary experience(s) of slight pleasure.
No experience(s) of pleasure in any social context or complete emotional indifference or neutrality in the company of people.

Item 2: Frequency of the experience of pleasure during social interactions

Very often: Many pleasurable experiences nearly every day
Frequently: Several pleasurable experiences most days
Often: Some pleasurable experiences most days
Sometimes: A few pleasurable experiences on about half of the days
Occasionally: A few pleasurable experiences on a few days
Rarely: Limited number of pleasurable experiences on a couple of days
Never: No pleasurable experiences

Experience of pleasure in anticipation of social interactions

If subject had contacts with friends, family, or partner:

Do you have any plans to spend time with your friends? Your family? Your spouse/partner?: How does it feel to think about the time you will spend with them? Are you looking forward to spending time with them? How does thinking about them make you feel?

If the subject had no or limited social interactions:

Would you like to have a close friendship or be involved with a boyfriend/girlfriend?: How does this possibility make you feel? Would you enjoy being in a close relationship? Tell me about it. Do you wish you had more people to spend time with? What would you like about that? How does it make you feel to think about spending more time with people?

Item 3: Intensity of experience of pleasure in anticipation of social interactions

Highly pleasurable experience. The experience is anticipated to be delightful or deeply satisfying ("amazing").
Strong pleasurable experience. The experience is anticipated to be very satisfying and fulfilling ("great", "wonderful", "fun").
Anticipated fairly strong pleasurable experience ("really good", "enjoyable").
Anticipated moderate pleasurable experience ("good").
Anticipated mild pleasurable experience (e.g., "nice" or "OK").
Anticipated minimal pleasurable experience.
No pleasure in anticipation of social interactions - completely indifferent about prospect of spending time with people.

Experience of pleasure from physical sensations

Did you engage in any physical activities over the past two weeks? Anything like exercising?

If yes: What did you do? How did these physical activities make you feel? What was that like? How often did you enjoy feeling that way?

How about spending time outdoors?

If Yes: What did you do? Did being outdoors make you feel good? What about it made you feel good? Did you see or smell anything in particular that you enjoyed?

Have you had any good meals this past week? Any drinks you enjoyed?

If Yes: Tell me about how it made you feel. How often did you have these good feelings?

Did you experience any physical intimacy with another person over the past week?

Did you experience any drive for sexual excitement? Did you experience any sexual arousal or excitement? If Yes: How did this feel? Were the experiences enjoyable for you? How often did you feel that way?

Over the past two weeks, did you experience any other pleasant physical sensations?

Any particular sensations like smelling things or hearing pleasant sounds that made you feel good? How often did you experience these pleasant feelings?

Item 4: Intensity of the experience of pleasure during physical sensations

Highly intense experience(s) of pleasure. The experience(s) was/were delightful or deeply satisfying ("amazing").
Strong experience(s) of pleasure. The experience(s) was/were very satisfying and fulfilling ("great", "wonderful", "fun").
Fairly strong experience(s) of pleasure ("really good", "enjoyable").
Moderate experience(s) of pleasurable ("good").
Mild experience(s) of pleasure (e.g., "nice" or "OK").
Fleeting or momentary experience(s) of slight pleasure.
No experience(s) of pleasure from physical sensations or complete emotional indifference or neutrality.

Item 5: Frequency of the experience of pleasure during physical sensations

Very often: Many pleasurable experiences nearly every day
Frequently: Several pleasurable experiences most days
Often: Some pleasurable experiences most days
Sometimes: A few pleasurable experiences on about half of the days
Occasionally: A few pleasurable experiences on a few days
Rarely: Limited number of pleasurable experiences on a couple of days
Never: No pleasurable experiences

Experience of pleasure while anticipating physical sensations

You mentioned that over the past couple of weeks you had several physical experiences like ______.

Do you expect to have any of these experiences in the next few weeks?
If Yes: What plans to you have? How does it feel when you think about doing these things? Are you looking forward to them?
If No: Do you wish that you did had activities planned in which you could experience these things? How would it make you feel if knew you would be able to experience them in the coming weeks?

What are some of the most pleasurable or enjoyable physical feelings that you can imagine experiencing?

Things like touching, tasting, or smelling certain things, or particularly pleasant sounds?

How do you think it would feel to engage in different physical activities that involve using the muscles of your body?

Things like exercising, dancing, gardening, riding a bike, or walking?

How do you think it would feel to get a massage? How about the feeling of sitting in a hot tub or a steam bath?

How much would you enjoy these activities?

Can you imagine being moved by the beauty of nature?

What would it feel like to be on top of a mountain and looking out at the scenery in every direction? Or things like looking out on a clear night and seeing the sky filled with stars?

Would you enjoy other smells, like the smell of a fireplace on a cold winter night?

Or other scents or aromas like a particular perfume/cologne, scented candles or soap?

If you could have any meal this coming week, what would you choose?

How do you think it would make you feel to eat ______ ?
Is there any particular drink you would choose to go along with that?
What would if feel like to drink a glass of ______?

Are there any particular types of music you would enjoy listening to?

How would it make you feel to listen to them?

Do you wish that sexual intimacy or excitement was a bigger part of your life?

When it comes to sex, some people feel as if they could take it or leave it - it really doesn't feel that good to them - how do you feel about it?
Do you enjoy the physical contact and sensations associated with sex?

Item 6: Intensity of the experience of pleasure anticipation of physical sensations

Highly pleasurable experience. The experience is anticipated to be delightful or deeply satisfying ("amazing").
Strong pleasurable experience. The experience is anticipated to be very satisfying and fulfilling ("great", "wonderful", "fun")
Anticipated fairly strong pleasurable experience ("really good", "enjoyable")
Anticipated moderate pleasurable experience ("good")
Anticipated mild pleasurable experience (e.g., "nice" or "OK").
Anticipated minimal pleasurable experience.
No pleasure in anticipation of social interactions - completely indifferent about prospect of spending time with people.

Experience of pleasure from recreational/vocational activities

What have you been doing for fun in your free time over the past two weeks?

Do you have any special hobbies or special interests that you've been involved in over the past two weeks?
If Yes: What kinds of things? What do you like about them?
How did it feel while you were _____?
How often did you enjoy these activities?

Are you a sports fan? Do you participate in any sports yourself?

If Yes: What have you been doing?
How did you feel when you were watching / playing _______.
How often did you enjoy these activities?

Have you been reading the paper or any special books or magazines?

If Yes: What have you been reading? How did you feel while you were reading?
How often did you enjoy doing these things?

Have you been watching any TV or seen any movies in the past two weeks?

If Yes: what have you been watching? Are those shows fun to watch?
How often did you have fun watching TV?

Have you been working or taking any classes over the past two weeks?

If Yes: Tell me about what you've been doing. Do you like work/school?
How much satisfaction or pleasure does you work give you?
How often did you feel this way?

Item 7: Intensity of the experience of pleasure during recreational/vocational activities

Highly intense experience(s) of pleasure. The experience(s) was/were delightful or deeply satisfying ("amazing").
Strong experience(s) of pleasure. The experience(s) was/were very satisfying and fulfilling ("great", "wonderful", "fun").
Fairly strong experience(s) of pleasure ("really good", "enjoyable").
Moderate experience(s) of pleasurable ("good").
Mild experience(s) of pleasure (e.g., "nice" or "OK").
Fleeting or momentary experience(s) of slight pleasure.
No experience(s) of pleasure in any recreational/vocational activity or complete emotional indifference or neutrality during these activities.

Item 8: Frequency of the experience of pleasure during recreational/vocational activities

Very often: Many pleasurable experiences nearly every day
Frequently: Several pleasurable experiences most days
Often: Some pleasurable experiences most days
Sometimes: A few pleasurable experiences on about half of the days
Occasionally: A few pleasurable experiences on a few days
Rarely: Limited number of pleasurable experiences on a couple of days
Never: No pleasurable experiences

Experience of pleasure while anticipating recreational/vocational activities

You mentioned that over the past two weeks you have been involved in _______. Do you have any plans to engage in these activities over the next few weeks?

If Yes: What are your plans? How does thinking about these plans make you feel?
Are you looking forward to any of these activities in particular?
How do you think it will feel when you actually _______.

Is there anything that you are looking forward to doing in your free time over the next few weeks?

If Yes: Tell me a bit about them. How does thinking about them make you feel?
Do you think they will be fun?

Do you wish that you had more to do during your free time?

If Yes: What kinds of things would you like to do?
What would you like about those things?

Is there anything that you can think of that you would enjoy doing in your free time?

If Yes: How does it make you feel to think about doing ________.

Would you like to work or go to school?

If Yes: What would you like to do/study?
How do you think working/being in school would make you feel?

Item 9: Intensity of the experience of pleasure anticipation of recreational/vocational activities

Highly pleasurable experience. The experience is anticipated to be delightful or deeply satisfying ("amazing").
Strong pleasurable experience. The experience is anticipated to be very satisfying and fulfilling ("great", "wonderful", "fun").
Anticipated fairly strong pleasurable experience ("really good", "enjoyable").
Anticipated moderate pleasurable experience ("good").
Anticipated mild pleasurable experience (e.g., "nice" or "OK").
Anticipated minimal pleasurable experience.
No pleasure in anticipation of social interactions - completely indifferent about prospect of spending time with people.

Anhedonia Subscale: Judgment of Cause

Item 10: Based on all available information, what is your judgment as to the principal cause of any observed deficit in anhedonia?

Choose only one.
If you think more than one makes a significant contribution, pick the most important factor.

_____ Does not apply, as all of the ratings are less than 2
_____ Depression and/or anxiety
_____ Suspiciousness
_____ Other hallucinations and/or delusions
_____ Disorganization
_____ Medication side effect or a general medical condition
_____ None of the above

Experience of Negative Emotion

What's made you feel bad in the last two weeks?

What's made you feel sad or depressed?

What's made you feel nervous, worried, or scared?

What do you find irritating?

Item 11: Intensity of the experience of negative emotions

severe negative emotions - Highly intense experience(s) of negative emotions. The experience(s) was devastating ("terrifying," "heartbreaking," worst thing that ever happened," "horrible," "overwhelming," etc.).
severe negative emotions - Strong experience of negative emotions ("very bad," "really scary," "very sad").
moderately severe negative emotions - Very unpleasant experience ("bad," "frightening," ""depressing").
moderate negative emotions - Definite experience(s) of negative emotions, but not of great importance or distress to the patient ("bothered me," "didn't like it).
mild negative emotions - Mild experience of negative emotions ("mixed feelings," "worse have been better").
very mild negative emotions - Mild preference not to have the same experience ("not that bad," "okay, I guess").
no negative emotions - No experience of negative emotions in any situation.

Item 12: Frequency of the experience of negative emotions

unrelenting - Dysphoric during all or nearly all waking hours.
very common -Negative emotions most of the time, with a few periods of feeling well or neutral.
usual - Negative emotions more than half of the time.
half - Negative emotions about half of waking hours.
less than half - Frequently has negative emotions, but clearly less than half of waking hours.
occasional - Occasional negative emotions.
no negative emotions - No negative emotions during the rating period.

II. Asociality Subscale

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Asociality indicates diminished social interactions. This may be evident in self-selected isolation, a preference for nonsocial activities, and avoidance of social encounters. When within a social setting the individual may engage in only superficial or fleeting exchanges. Separate ratings of social behavior are obtained for family, romantic and friends/other social relationships. Ratings should not reflect pleasure derived from any social activities (see Anhedonia) but reflect only the frequency and nature of the interaction as described below.

In evaluating the social behavior of the individual one should consider two aspects of social activities: a) the frequency of social activities and b) the nature of the social interactions.

Frequency: This reflects how often an individual interacts with others during the assessment period. Frequency should consider the full range of social activities from spontaneous conversations, phone calls to friends or relatives, and more structured activities such as going out to dinner with friends, a date, or attending a party.
Nature of Interaction: In considering the social interactions reported, ratings should reflect the quality of the individual's actual social engagement. That is, to what degree do social activities involve the individual's active participation and reflect a true social interaction? Although an individual may have frequent social contacts a higher rating for Asociality may be justified if these activities are entirely superficial (e.g., merely involving exchange of social greetings; lack any sustained contact or interaction between participants). Descriptions of the social contacts will allow one to determine if these should be considered genuine social activities (e.g., involving one-on-one interaction, conversation, and in closer relationships may include intimate self-disclosure) or if they may more accurately reflect superficial exchanges (e.g., a "conversation" at a diner is in actuality the waitress taking a dinner order; "meeting a friend" may only involve saying hello to a neighbor as they pass each other in the hallway; "going to a party" is a birthday party put on by staff at group home where subject passively attends, sits alone, and does not interact with others).

Family

Have you been in contact with or visited with any family members in the past two weeks?: Did you talk on the phone or exchange e-mail or letters with any relatives?

If no contact:

Determine why there has been no contact: Do you have any relatives? Where do they live?
Have they tried to contact you or visit you in the two weeks?
Would you know how to contact them?

If there is contact:

What kinds of things have you done with your family?: How often have you done [activity] in past two weeks? How much time did you spend together?

Tell me about what you did during that [visit, activity, conversation]?

When you were together, who does the talking?: What did you talk about?

Item 13:

no impairment - subject has frequent and involved social activities with family members, well within normal limits.
very slight deficit - very slight deficit in frequency and involvement in social interactions with family members, of questionable clinical relevance.
mild deficit - a mild deficit in frequency and involvement in social interactions with family members . The subject may report initiating a family interaction 5-7 times in the past 2 weeks, with moderate involvement in the social exchanges.
moderate deficit - notable deficit in frequency and involvement in social interactions with family. The subject may have had 4-5 interactions and/or not been very involved in these social interactions.
moderately severe deficit - significant deficit in frequency and involvement in social interactions with family members. The subject may have had 3-4 interactions with family but these are superficial contacts.
marked deficit - obvious lack of frequency and involvement in social interactions with family members. Subject may had had 1-2 superficial interactions in the past two weeks.
severe deficit - total lack of social interactions with family members.
not rated - Has no living family.

Romantic
Suggested questions:

Have you been in a romantic relationship in the past two weeks?

__Individual reports no romantic relationship (rate 6).
If yes:

Tell me about that relationship.

How long have you been together? Do you live together? Have you been in contact with or seen [romantic partner] in last two weeks? Are you seeing anyone else? How often?

If contact:

What kinds of things have you done with [partner]?

How often have you done [activity] in past two weeks? How much time did you spend together?

For each activity, determine degree of involvement and actual social interaction occurring in the activity:
Tell me about what you did during that [visit, activity, conversation]?

If subject describes partner's behavior during activity be sure to clarify and have subject describe their own involvement and how they interacted with partner.
When you were together, who does the talking?

What did you talk about?

Item 14:
1. no impairment - subject has frequent and involved social activities with romantic partner(s), well within normal limits.
2. very slight deficit - very slight deficit in frequency and involvement in social interactions with romantic partner(s), of questionable clinical relevance.
3. mild deficit - a mild deficit in frequency and involvement in social interactions with romantic partner(s). The subject may report initiating an interaction 5-7 times in the past 2 weeks, with moderate involvement in the social exchanges.
4. moderate deficit - notable deficit in frequency and involvement in social interactions with romantic partner(s). The subject may have had 4-5 interactions and/or not been very involved in these social interactions.
5. moderately severe deficit - significant deficit in frequency and involvement in social interactions with romantic partner(s). The subject may have had 3-4 interactions with partner(s) but these were only superficial.
6. marked deficit - obvious lack of frequency and involvement in social interactions with romantic partner(s). Subject may had had 1-2 superficial interactions in the past two weeks.
7. severe deficit - has no romantic partner or total lack of social interactions with romantic partner(s).
Friends

Do you have any friends? Anyone that you are close to and can confide in?: Individual reports having no friends (rate 6).

Tell me about your friendships.: Have you been in contact with or seen [friend] in last two weeks?

In the past two weeks, what kinds of things have you done with your friends?: How often have you done [activity] in past two weeks? How much time did you spend together?
When you were together, who does the talking?: What did you talk about?

Item 16:

no impairment - subject has frequent and involved social activities with others, well within normal limits.
very slight deficit - very slight deficit in frequency and involvement in social interactions with others, of questionable clinical relevance.
mild deficit - a mild deficit in frequency and involvement in social interactions with others. The subject may report initiating an interaction 5-7 times in the past 2 weeks, with moderate involvement in the social exchanges.
moderate deficit - notable deficit in frequency and involvement in social interactions with others. The subject may have had 4-5 interactions and/or not been very involved in these social interactions.
moderately severe deficit - significant deficit in frequency and involvement in social interactions with friend(s). The subject may have had 3-4 interactions with others but was only superficially involved.
marked deficit - obvious lack of frequency and involvement in social interactions with others. Subject may had had 1-2 superficial interactions in the past two weeks.
severe deficit - has no social interactions with others.

Asociality Subscale: Judgment of Cause

Item 17:

Choose only one.

III. AVOLITION SUBSCALE

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Avolition refers to a lack of behavioral initiation and persistence across several domains, including social relationships, work/vocation/school, recreation/hobbies/pastimes, and self-care. Interview prompts are intended to elicit discussion about whether subjects have initiated and persisted in behaviors across these domains. To avoid conflation with anhedonia, this rating should assess subject's interests as they are manifested in behavior. In other words, anhedonia ratings will assess what subjects derive pleasure from; avolition ratings will assess what subjects actually do and initiate in their behavior, regardless of any pleasure or enjoyment derived from an activity. To minimize conflation with measures of functional outcome, the rating of avolition will be concerned with how broadly a subject is initiating goal-directed behavior across domains, rather than whether a subject happens to be doing an activity in a domain at a given point in time. To minimize conflation with asociality, ratings of avolition in social relationships are concerned with initiation of social activities whereas ratings of asociality are concerned with quality and frequency of social interactions. Finally, subjects who report participating in many activities because they are required to (as in, for example, a day treatment program) but do not initiate these activities may receive a higher score on avolition that subjects who initiate a smaller number of activities.

When you spent time with other people in the past two weeks, who initiated [arranged the get together; set it up] ?

Did others ask you to do something more than you asked them?

When you wanted to see a friend, what did you do? How often have you done this in the past two weeks?

What sorts of steps did you take to see other people in the past two weeks?

When you were with other people, who decided what you will do?

How much time did you spend with other people? Is that by your choice?

Have you tried to meet any new people in the past two weeks?

Item 18

no impairment - initiates and persists in social interactions or relationships, within normal limits.
very slight deficit - very slight deficit in initiating and persisting in interactions or relationships. Questionable clinical relevance.
mild deficit - mild deficit in initiating and persisting; may initiate interactions 5-7 times in the past 2 weeks, with moderate persistence.
moderate deficit - notable deficit in initiating; may initiate 4-5 interactions and/or not persist for very long.
moderately severe deficit - significant deficit in initiating; may initiate 3-4 exchanges but not persisted for very long.
marked deficit - obvious lack of initiation and persistence; may initiate1-2 exchanges.
severe deficit - nearly total lack of initiation of interactions and relationships.

Work/Vocational/School Activities

If currently working or going to school:

Did you get to your job on your own? How did you get to school?

Did someone need to remind you about work? How did you keep up with your school schedule?

Did you take on new tasks at work in the past two weeks (or do you wait for others to tell you what to do)?

When at your job, how many breaks do you usually need to take? How often have you missed class?

Have you been able to complete tasks or responsibilities at work? Have you been completing your homework assignments? Have you been missing any days?

Have you been interested in learning new things at your job? Doing new projects at school?

If not currently working:

How often have you looked for work in the past two weeks? Have you looked into taking classes during the last two weeks?

How did you go about finding a job or place to volunteer? How did you go about getting into school?

Have others prompted you to look for a job or take classes?

Can you look for a job on your own? Are you able to figure out how to get in school on your own?

Are you interesting in learning new things from a job? Are you interested in going to school?

Item 19:

no impairment - initiates and persists in work, school, or job-seeking on a regular basis.
very slight deficit - very slight deficit in initiating and persisting. Of questionable clinical relevance.
mild deficit - a mild deficit in initiating and persisting; may report 5 or more instances, with moderate persistence.
moderate deficit - notable deficit in initiating; may have initiated 3-4 activities; needed reminders on multiple occasions, not initiated any new activities, and/or not persisted for very long.
moderately severe deficit - significant deficit in initiating; may have needed constant reminders, and/or initiated 1-2 activities. Did not persist for very long.
marked deficit - obvious lack of initiation and persistence; must be taken to job/school else would not go; may have done 1 brief work/school activity.
severe deficit - nearly total lack of initiation and persistence in work, school, or job-seeking.
not rated - subject is in the hospital for the duration of the rating period

Recreation/Hobbies/Pastimes

What types of things do you do in your free time?

What hobbies do you have?
Do you have any recreational activities that you participate in, such as sports or other hobbies?

How often did you do your {hobbies}?

When you wanted to do an activity, did you go ahead and do it or did others prompt you to do it?

How long did you do {hobby, recreational activity} once you started?

Have you tried something new in the past two weeks?

Item 20:

no impairment - initiates and persists in hobbies and recreational activities on a regular basis.
very slight deficit - very slight deficit in initiating and persisting. Of questionable clinical relevance.
mild deficit - a mild deficit in initiating and persisting; may report 5 or more instances and moderate persistence.
moderate deficit - notable deficit in initiating; may have done 3-4 activities and/or not persisted for very long.
moderately severe deficit - significant deficit in initiating and persisting; may have done 1-2 activities and not persisted for very long.
marked deficit - obvious lack of initiation and persistence; may have done just 1 activity.
severe deficit - nearly total lack of initiation and persistence in hobbies or recreational activities.

Self-Care

How often did you see you doctor?

Have you tried to get a doctor's appointment?

Have you worked to obtain or maintain your benefits?
Have you needed to look for a place to live?

How have you gone about that?

How often have you showered/bathed over the past two weeks?

Has someone needed to remind you do this?

Have you paid attention to the way you look?

How often have you put on a new change of clothes? Does someone needed to remind you do this?

How often have you brushed your teeth and combed or brushed your hair?

Did someone need to remind you do this?

How often have you done your laundry?

Did someone need to remind you do this?

How often did you clean your {apartment, room, house}?

Did someone need to remind you do this?

Item 21:

no impairment - no deficit in initiating and persisting in self-care.
very slight deficit - very slight deficit in initiating and persisting; may look very slightly disheveled or slight self-care neglect. Of questionable clinical relevance.
mild deficit - mild deficit in initiating and persisting; may show or report 1-2 mild deficits in self-care.
moderate deficit - notable deficit in initiating and persisting; may exhibit and/or report 3-4 self-care problems.
moderately severe deficit - significant deficit in initiating and persisting; may exhibit or report 5 or more self-care problems.
marked deficit - obvious lack of initiation and persistence in self-care. Problems in all areas of self-care and grooming; little self-care prior to the interview.
severe deficit - nearly total lack of self-care; may appear completely disheveled, and report very poor self-care.

Judgment of Cause

Item 22:

Based on all available information, what is your judgment as to the principal cause of any observed deficit in avolition?
Choose only one. If you think more than one makes a significant contribution, pick the most important factor.
_____ Does not apply, as all of the ratings are less than 2
_____ Depression and/or anxiety
_____ Suspiciousness
_____ Other hallucinations and/or delusions
_____ Disorganization
_____ Medication side effect or a general medical condition
_____ None of the above

Introduction to the Blunted Affect and Alogia Subscales

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As one of the two components of negative symptoms in schizophrenia, reductions in expressivity can take several forms. These include reduced emotional expression and reduced verbal output. Reductions in these domains are rated observationally, on the basis of the interview questions asked and the subject's responses to them and the general behavior of the subject during the interview. All observational sources should be considered, including spontaneous behavior and direct responses to questions over the course of the entire interview.

Please note that there are multiple dimensions of reduced expression and the scale attempts to rate them independently. In generating ratings, the evaluator should make every effort not to "carry-over" ratings from one item to another. For instance, reduced vocal expression does not signify reduced verbal output and the rater should make every effort to consider them separately. Also, the content of communications does not always reflect the form of the communications. If an individual describes being depressed, but does so in a way that is consistent with reduced facial and vocal expression, the expression should be rated, regardless of the content that is being presented.

Inferential ratings should be avoided. Ratings should reference the currently observable state of the subject and should avoid attempts at "understanding" the reasons for the behavior. Reduced verbal output does not necessarily reflect reduced cognitive activity, and vice versa, and all raters should strive to rate the patient as they are observed, on the day that they are observed.

IV. BLUNTED AFFECT SUBSCALE

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Blunted affect refers to a decrease in the outward expression of emotion, and the prompts interview are designed to elicit emotion. There are no specific probes for Alogia subscales; ratings are based on the responses to other questions during the interview. If the subject does not respond to the prompts asking about emotional experiences, this item can be rated based on the responses to other questions during the interview. Be sure to note at the bottom of the scale the basis for the rating. Be sure to ask questions that elicit BOTH positive and negative emotion. Prompts about negative emotion are asked for the negative emotion experience item. If the subject does not respond to the prompts asking about emotional experiences, items can be rated based on the responses to other questions during the interview. Be sure to note at the bottom of each rating scale the basis for the rating.

What do you enjoy?
What makes you feel good?
What excites you?
Tell me about a time when you recently felt happy

Facial Expression

When making the facial expression rating, consider facial movements across all parts of the face, including in the eyes (e.g., raised brows), mouth (smiling or grimacing), and mid-face (e.g., wrinkled nose when disgusted).

Item 23:

no impairment - Well within normal limits; animated talking of emotional experiences, with many appropriate changes in facial expressions.
very slight deficit - Very slight decrease of questionable clinical relevance in the frequency and intensity of facial expressions when recounting emotional experiences.
mild deficit - Mild decrease in the frequency or intensity of facial expressions; shows at least two changes in the face during the recounting of each emotional experience.
moderate deficit - Notable decrease in the frequency and intensity of facial expressions, such as showing only one change in facial expression in response to each question.
moderately severe deficit - Significant lack of facial expressions when recounting emotional experiences, showing facial expressions for only one or two questions; may show only three or four changes in expression in the entire conversation.
marked deficit - Obvious lack of positive and negative facial expressions in response to all questions; may show only one or two slight changes in facial expression during the entire conversation.
severe deficit - Nearly total lack of facial expressions throughout the conversation.

Vocal Expression

One of the components of blunted affect is modulation of the voice. Three dimensions should be considered: variation in the speed, volume, and pitch of what is spoken (words as well as other speech). The content of speech is not rated here.

Item 24:

no impairment - Normal expression of affect, with normal changes in speed, volume, and pitch of speech apparent.
very slight deficit - Slight decrease in vocal expression of affect; of questionable clinical significance.
mild deficit - Mild but definite decrease in vocal expression of affect.
moderate deficit - Moderate decrease in vocal expression of affect; decrease may not be noticed immediately.
moderately severe deficit - Decrease in vocal expression of affect is easily noticed.
marked deficit - Decrease in vocal expression of affect is readily apparent throughout the interview.
severe deficit - No or almost no vocal expression of affect.
not rated - Subject does not speak.

Expressive Gestures

Expressive gestures include gestures made with the head (e.g. nodding), shoulders (shrugging), arms and hands (pointing), and trunk (moving forward).

Item 25:

no impairment - gestures are well within normal limits; uses many gestures of the arms, hands, shoulders, head, and/or body when recounting emotional experiences.
very slight deficit - very slight decrease in the frequency of expressive gestures; of questionable clinical relevance, a slight decrement in the use of the arms, hands, head, or body.
mild deficit - a mild decrease in the frequency of expressive gestures; exhibits at least two expressive gestures during the recounting of each emotional experience.
moderate deficit - Notable decrease in the frequency expressive gestures; may show a slight gesture in response to each question.
moderately severe deficit - significant lack of expressive gestures exhibiting a gesture in response to only one or two of the questions; may show only three or four gestures throughout entire conversation.
marked deficit - obvious lack of expressive gestures. The reduced number of gestures occurs for all questions; may show only one or two slight gestures throughout the entire conversation.
severe deficit - nearly total lack of expressive gestures; virtually no movement of arms, hands, head or body when recounting all emotional experiences.

Eye Contact

The eye contact rating is focused on the lack of eye contact rather than the subject's "staring through" the interviewer and holding an intense gaze throughout the conversation.

Item 26:

no impairment - well within normal limits, the subject seeks and maintains appropriate eye contact throughout the conversation.
very slight deficit - very slight decrease in the frequency of eye contacts sought by the subject or a minimal tendency of the subject to avoid eye contact initiated by the examiner; of questionable clinical relevance, but nonetheless a slight decrement in eye contact during the conversation.
mild deficit - a mild decrease in the frequency of eye contacts. The subject looks away on at least two occasions when recounting emotional experiences or in response to questions.
moderate deficit - Notable decrease in the frequency of eye contacts. The subject responds without establishing eye contact, such as having eye contact once in response to each question.
moderately severe deficit- significant lack of eye contact when recounting emotional experiences. The subject may show only three or four brief eye contacts throughout the entire conversation.
marked deficit - obvious lack of eye contact evident during the recounting of emotional experiences. The reduced eye contact occurs for all questions and the subject may show only one or two brief eye contacts during the entire conversation.
severe deficit - nearly total lack of eye contact such that the subject shows virtually no initiation of eye contact when recounting all emotional experiences during the conversation and avoids all eye contact attempts initiated by the interviewer.

Spontaneous Movements

When rating spontaneous movements, consider all such movements, including adjustment of position, crossing arms, and shifting legs.

Item 27:

no impairment - well within normal limits, the subject maintains typical body movements, such as adjusting position, crossing arms, shifting of the legs, throughout the conversation.
very slight deficit - very slight decrease in the frequency of spontaneous movements; of questionable clinical relevance, but nonetheless a slight decrement in movement of the body during the conversation.
mild deficit - a mild decrease in the frequency of body movements. The subject moves on at least two occasions when recounting each emotional experience or in response to questions.
moderate deficit - Notable decrease in the frequency of spontaneous movements. The subject may have a slight movement when recounting an emotional experience or in response to each question.
moderately severe deficit - significant lack of spontaneous movements when recounting emotional experiences, showing spontaneous movements for only one or two of the questions. The subject may show only three or four spontaneous movements throughout the entire conversation.
marked deficit - obvious lack of spontaneous movements evident during the recounting of emotional experiences. Reduced spontaneous movements occurs for all questions and the subject may show only one or two brief spontaneous movements during the entire conversation.
severe deficit - the subject shows virtually no spontaneous movements when recounting all emotional experiences during the conversation.

Blunted Affect Subscale: Judgment of Cause

Item 28:

Blunted Affect Subscale: Basis of Rating

V. ALOGIA SUBSCALE

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Quantity of Speech

This item refers to the simple quantity of words spoken. Such abnormalities as disorganization, neologisms, or psychotic content are not rated here. Mutism is rated as a 9.

Item 29:

no impairment - normal amount of speech
very slight deficit - Questionable decrease in the quantity of speech; answers provides appropriate information and sufficient detail, but answers are typically concise.
mild deficit - Although sufficient information is usually provided, the amount of detail is less than desirable or appropriate; the interviewer may have to repeat queries.
moderate deficit - At times sufficient information or appropriate detail is not provided; the interviewer commonly has to repeat queries or ask in another way.
moderately severe deficit - At least half of the replies are monosyllabic or very brief
marked deficit - Most answers are monosyllabic.
severe deficit - All or nearly all replies are monosyllabic.
not rated - Subject does not speak

Introduction of New Topics

This item rates the subject's contribution to the topics discussed in the interview. New topics can include background information given to clarify a question, resulting in the subject's giving more than the minimum amount of information needed to answer a question.

Item 30:

no impairment - Interaction between subject and rater is more like a conversation than an interview, with subjects introducing new topics freely. The interview may even be overly talkative or have pressure of speech.
very slight deficit - Subject freely introduces many new topics, with background information given frequently, or numerous opportunities taken to chat with the interviewer.
mild deficit - Subject introduces several new topics, but is usually focused on just the information that is required.
moderate deficit - Definite decrease in number of new topics introduced.
moderately severe deficit - Subject introduces few new topics, but has at least one clear digression that is not strictly needed.
marked deficit - Most answers provide just the information needed.
severe deficit - Subject does not introduce any new topics.
not rated - Subject does not speak

Alogia Subscale: Judgment of Cause

Item 31:

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