Bush-Francis Catatonia Rating Scale (BFCRS)

The Bush- Francis Catatonia Rating Scale (BFCRS) is a standardised, quantifiable examination of catatonia designed to screen and diagnose the possibility of catatonia.  The BSRCS was designed by Bush, Fink, Petrides, Dowling and Francis in 1996 and is based on descriptors of catatonia from the literature and motor signs identified in the DSM-III, IV and ICD-10 criteria.

The BFCRS consists of a 23- item rating scale with the first 14 items comprising the Bush Francis Catatonia Screening Instrument (BFCSI).  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 standardised examination procedure consisting of nine steps.   Sample procedures are: 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)

The BFCRS was tested on a sample of 28 acutely ill patients presenting with catatonic syndrome from an acute psychiatric inpatient clinic and a university hospital.  No information on gender is available (Wong, Ungvari, Leung and Tang, 2007). Both the BFCRS and the BFCSI showed a high inter-rater reliability: r= 0.93 and r = 0.95 respectively.  Test re-test reliability was not studied because of the fluctuating course of the catatonic syndrome.

Validity was harder to assess because of the lack of established diagnostic criteria. Diagnostic agreement between cases in the BFCSI and previously published criteria for catatonia ranged from 75 – 100% (Bush et al., 1996). Validity of the scale was also examined by comparison with the sources from which it was derived. Of the 23 items, 96% were included in at least two sources (Bush et al.). The only language the BFCRS has been translated into is Portuguese and the scale remained as reliable and valid as in the original instrument (Santos Nunes et al., 2017).

The BFCRS is currently the preferred rating scale for the detection of catatonia due to its five minute administration time and reliability and validity.  However, recent research found that the BFCRS-0 and BFCRS-R may be more suitable for a schizophrenic population (Wong et al., 2007).  Wilson, Niu, Nicolson, Levine and Heckers (2015) also found it to have low reliability at the low severity level but good reliability at the moderate to severe level.

The BFCRS and examination procedure is freely available and can be accessed online at: Bush, G., Fink, M., Petrides, G., Dowling, F., Francis, A. (1996). Catatonia.1. Rating scale and standardized examination. Acta Psychiatrica Scandinavica, 93, 129-136.


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