Positive and Negative Syndrome Scale (PANSS)

The Positive and Negative Syndrome Scale (PANSS) is a rating scale, designed on the premise that schizophrenia comprises of: positive syndrome, pertaining to productive symptoms; and negative syndrome, pertaining to deficit features (Depp et al, 2010). This clinical tool is employed: 1) upon an inpatient’s admission 2) at the outset of taking a new medication and 3) weeks/ months into treatment to gauge the effect of the intervention (Opler et al., 2006). PANSS has been published officially across 40 languages following internationally valued and sanctioned guidelines under the Multi Health Systems (MHS) Translation Policy (Khan et al, 2013). Validation studies conducted in 1994, conducted reliability and validity studies among 100 DSM-III-R schizophrenic patients. Cuesta and Peralta (1994) much like Opler (1987) found that the scores were normally distributed; while the construct validity was adequate, the positive and negative subscales when compared to Scales for the Assessment of Positive/Negative Symptoms, depicted high criterion validity. However the internal consistency was insufficient and factorial validity of the positive scale was poor. The scale was seemingly developed on the basis of independent components; furthermore, it oversimplified the negative and positive symptoms. PANSS has since had alternate versions released – PANSS – SCI which accompanies a structured clinical interview and IQ –PANSS, which acquires information from informants such as family/case workers (MHS, 2006). Despite complications with respect to length and ability to measure cognitive functioning, PANSS is considered a competent “stand-alone” clinical screening tool for psychosis due to its clinical predicting power and outcome.

Newer studies communicate the following psychometric properties:
Adequate Internal consistencies for positive (α = 0.73: Acceptable), negative (α = 0.83: Good), and general psychopathology (α = 0.79: Good) subscales. Good test-retest reliability with Pearson correlation coefficients at 0.80, 0.68, and 0.60 for the positive, negative and psychopathology subscales. Positive and negative scales showed good inter-rater reliability. Interclass correlation coefficients of 0.72 and 0.80, respectively. Inter-rater reliability was moderate (0.56) for the general psychopathology scale.


Canadian Agency for Drugs and Technologies in Health. (2011) A systematic review of combination and high dose atypical antipsychotic therapy in patients with schizophrenia. Ottawa: CADTH

Cuesta, M. J., & Peralta, V. (1995). Psychopathological dimensions in schizophrenia. Schizophrenia Bulletin, 21(3), 473-482.

Kay SR, Opler LA, Fiszbein A. Positive and Negative Syndrome Scale (PANSS; 2006) manual. Toronto, Ontario: MultiHealth Systems, Inc.

Khan, A., Christian Yavorsky, C., Liechti, S., Opler, M., Rothman, B., Diclemente, G., Lucic, L., Jovic, S., Inada, T. and Yang, L. (2013). Available at: http://A rasch model to test the cross-cultural validity in the positive and negative syndrome scale (PANSS) across six geo-cultural groups [Accessed 17 Sep. 2017].

Kumari S, Malik M, Florival C, Manalai P, Sonje S (2017) An Assessment of Five (PANSS, SAPS, SANS, NSA-16, CGI-SCH) commonly used Symptoms Rating Scales in Schizophrenia and Comparison to Newer Scales (CAINS, BNSS). J Addict Res Ther 8: 324. doi: 10.4172/2155-6105.1000324

Maust, D., Cristancho, M., Gray, L., Rushing, S., Tjoa, C. and Thase, M. (2012). Psychiatric rating scales. [online] Experts.umich.edu. Available at: https://experts.umich.edu/en/publications/psychiatric-rating-scales [Accessed 17 Sep. 2017].

Opler, L. A., Opler, M. G. and Malaspina, D. 2006. Reducing guesswork in schizophrenia treatment: PANSS can target and gauge therapy, predict outcomes in clinical practice. Current Psychiatry, 5: 76–84.

Taylor, Grantley W; McCarley, Robert W; Salisbury, Dean F (2013) Early auditory gamma band response abnormalities in first hospitalized schizophrenia. Suppl Clin Neurophysiol 62:131-45




Calgary Depression Scale for Schizophrenia (CDSS)

Depression is reported to be prevalent in 7–75% of patients with schizophrenia, with an average of 25% (Kim et al., 2006; Müller et al., 2005). During the late 1980’s, depression in schizophrenia generated substantial research attention because of its importance in diagnosis, treatment and long-term outcomes of the disorder. Scales for assessing depression in non-psychotic populations have been criticised for being inappropriate for assessing depression in individuals with schizophrenia.

The Calgary Depression Scale for Schizophrenia (CDSS) is a nine item structured interview scale that was designed in 1990 specifically to assess depression independently of symptoms of psychosis in schizophrenia. Originally an 11 item scale (Donald Addington, Addington, & Schissel, 1990), the CDS was developed from, and validated against, the Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI), and the Brief Psychiatric Rating Scale (BPRS) using factor analysis, internal consistency, and face validity (Donald Addington, Addington, Maticka-Tyndale, & Joyce, 1992; Donald Addington et al., 1990).

The CDS consists of eight structured questions and a ninth observational item that depends on observation over the course of the interview (Kim et al., 2006). Items were constructed to measure: 1. Depression; 2. Hopelessness; 3. Self deprecation; 4. Guilty ideas; 5. Pathological guilt; 6. Morning depression; 7. Early wakening; 8. Suicidal ideation; and 9. Observed depression.

Items are graded on a 4-point Likert type scale (0, absent; 1, mild; 2, moderate; 3, severe), anchored by descriptors (Donald Addington et al., 1992). Point scores of all nine items are summed to obtain the CDS depression score. A score higher than 6 has an 82% specificity and 85% sensitivity for predicting the presence of a major depressive episode.

Psychometric properties

  • Reliable, valid and specific measure of depression in patients with schizophrenia. Measures depression separately from negative and extrapyramidal symptoms. Low correlation with positive and negative symptoms and no substantial correlation with extrapyramidal symptoms
  • High internal consistency: α = 0.76 – 0.86
  • Good internal and inter-rater reliability:
  • High validity: Ability to predict presence of MDD; 2. Correlation with other depression measures; 3. Confirmatory factor analysis
  • Strong construct validity: Single dimension being measured. Confirmed by correlations with other depression rating scales and prediction of major depressive episode
  • Divergent validity: Absence of correlations with positive negative and extrapyramidal symptoms


  • Used in clinical populations of patients with depression in schizophrenia (DSM-III-R, DSM-IV)
  • Focused on maximising internal and external validity across inpatients and outpatients
  • Has been translated into 40 languages. Validated in: Arabic, Spanish, German, Chinese, Thai, Brazilian, Greek, French


  • Quick to administer
  • Sensitive to change, so can be used at both the acute and residual stages of schizophrenia
  • Superior to the Hamilton Depression Rating Scale (HDRS) and Montgomery-Asberg Scale for differentiating between depression and negative and positive symptoms. All items significantly discriminate between the presence and absence of a major depressive episode
  • Most specific and valid assessment of depression in schizophrenia


  • Scale is designed for use by an experienced rater. It is not intended for self assessment



Addington, D., Addington, J., & Maticka-Tyndale, E. (1991). Reliability and validity of a depression scale for schizophrenics. Schizophrenia Research, 4(3), 247. https://doi.org/10.1016/0920-9964(91)90089-A

Addington, D., Addington, J., & Maticka-Tyndale, E. (1994). Specificity of the Calgary Depression Scale for schizophrenics. Schizophrenia Research, 11(3), 239-244. https://doi.org/10.1016/0920-9964(94)90017-5

Addington, D., Addington, J., Maticka-Tyndale, E., & Joyce, J. (1992). Reliability and validity of a depression rating scale for schizophrenics. Schizophrenia Research, 6(3), 201-208. https://doi.org/10.1016/0920-9964(92)90003-N

Addington, D., Addington, J., & Schissel, B. (1990). A depression rating scale for schizophrenics. Schizophrenia Research, 3(4), 247-251. https://doi.org/10.1016/0920-9964(90)90005-R

Addington, J., Shah, H., Liu, L., & Addington, D. (2014). Reliability and validity of the Calgary Depression Scale for Schizophrenia (CDSS) in youth at clinical high risk for psychosis. Schizophrenia Research, 153(1), 64-67. https://doi.org/10.1016/j.schres.2013.12.014

Galletly, C., Castle, D., Dark, F., Humberstone, V., Jablensky, A., Killackey, E., Kulkarni, J., McGorry, P., Nielssen, O., Tran, N. (2016). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian & New Zealand Journal of Psychiatry, 50(5), 410-472. doi:10.1177/0004867416641195

Kim, S.-W., Kim, S.-J., Yoon, B.-H., Kim, J.-M., Shin, I.-S., Hwang, M. Y., & Yoon, J.-S. (2006). Diagnostic validity of assessment scales for depression in patients with schizophrenia. Psychiatry Research, 144(1), 57-63. https://doi.org/10.1016/j.psychres.2005.10.002

Lançon, C., Auquier, P., Reine, G., Bernard, D., & Toumi, M. (2000). Study of the concurrent validity of the Calgary Depression Scale for Schizophrenics (CDSS). Journal of Affective Disorders, 58(2), 107-115. https://doi.org/10.1016/S0165-0327(99)00075-0

Müller, M. J., Brening, H., Gensch, C., Klinga, J., Kienzle, B., & Müller, K.-M. (2005). The Calgary Depression Rating Scale for schizophrenia in a healthy control group: Psychometric properties and reference values. Journal of Affective Disorders, 88(1), 69-74. https://doi.org/10.1016/j.jad.2005.04.005

Brief Psychiatric Rating Scale (BPRS)

Available from: http://www.smchealth.org/sites/main/files/file-attachments/bprsform.pdf


  • Developed in the early 1960s by Overall and Gorham, using factor analysis.
  • Designed to assess the severity of schizophrenic states, with the aim of providing clinicians a way to quickly assess patient change
  • Each of the 18 items are designed to represent a discrete symptom area.
  • The scale is completed after an 18-min clinical interview.
  • Each of the 18 items takes roughly 2 – 3 mins to complete following the interview.
  • Five of the items (tension, emotional withdrawal, mannerisms and posturing, motor retardation and uncooperativeness) are based on observations of the patient. The remaining 13 items are based on the patient’s verbal report.
  • Items are rated on a 7-point Likert scale, from 1 = “not present” to 7 = “extremely severe”, with scores ranging from 18 to 126 (achieved through summing the item scores).

Psychometric properties:

  • Inter-rater reliability for the scales: range from 0.56 (tension) to 0.87 (guilt feelings and hallucinatory behaviour)
  • Inter-rater reliability for overall scores: range from 0.67 to 0.95
  • Divergent reliability: questionable, should not be used to differentiate diagnosis (even though original citation provides scoring weights for 13 diagnostic types)
  • Convergent reliability: up to 0.93 (depending on what it is being compared to).
  • Can differentiate between inpatient and outpatient populations

Settings and populations:

·        Inpatient psychiatric units ·        Forensic populations
·        Community care settings ·        Deaf populations
·        Research ·        Validated in the Netherlands
·        Drug & alcohol populations ·        Validated in Scandinavia



  • Methodological soundness (i.e. based on research/factor analysis)
  • Widely used in research and clinical populations, enabling comparisons of outcome data
  • Lack of redundancy in items
  • With training nurses and social workers can also use it and produce high inter-rater reliability
  • Does not require patients to be able to read or write, as it is clinician administered


  • Raters need experience to elicit information about symptoms not obvious or accessible to the patient.
  • Requires training in operational definitions
  • Requires regular refresher training to counter rater drift from established protocols
  • There are is no explicit time frame specified for the ratings
  • There are no operational definitions for the ratings or score cut-offs

Cultural and gender considerations:

  • There are no differences in scores assigned based on age or gender
  • No cultural issues identified – however attitudes and beliefs held by clinicians will impact ratings. Clinicians need to be aware of the norms of the person they are rating, to account for cultural frames of references (in terms of assessing the presence or absence of psychopathology) – particularly important in schizophrenia.


Andersen, J., Larsen, J. K., Schultz, V., Nielsen, B. M., Korner, A., Behnke, K., . . . Bech, P. (1989). The Brief Psychiatric Rating Scale. Dimension of schizophrenia–reliability and construct validity. Psychopathology, 22(2-3), 168-176. doi: 10.1159/000284591

Dingemans, P. M., Winter, M.-L. F.-d., Bleeker, J. A. C., & Rathod, P. (1983). A cross-cultural study of the reliability and factorial dimensions of the Brief Psychiatric Rating Scale (BPRS). Psychopharmacology, 80(2), 190-191. doi: 10.1007/bf00427968

Hafkenscheid, A. (1991). Psychometric evaluation of a standardized and expanded Brief Psychiatric Rating Scale. Acta Psychiatrica Scandanavica, 84(3), 294-300. doi: 10.1111/j.1600-0447.1991.tb03147.x

Horton, H. K., & Silverstein, S. M. (2011). Factor structure of the BPRS in deaf people with schizophrenia: Correlates to language and thought. Cognitive Neuropsychiatry, 16(3), 256-283. doi: 10.1080/13546805.2010.538231

Leucht, S., Kane, J. M., Kissling, W., Hamann, J., Etschel, E. V. A., & Engel, R. (2005). Clinical implications of Brief Psychiatric Rating Scale scores. The British Journal of Psychiatry, 187(4), 366.  Retrieved from http://bjp.rcpsych.org/content/187/4/366.abstract

Ligon, J., & Thyer, B. A. (2000). Interrater reliability of the Brief Psychiatric Rating Scale used at a community-based inpatient crisis stabilization unit. Journal of Clinical Psychology, 56(4), 583-587. doi: 10.1002/(SICI)1097-4679(200004)56:4<583::AID-JCLP12>3.0.CO;2-U

McGorry, P. D., Goodwin, R. J., & Stuart, G. W. (1988). The development, use, and reliability of the brief psychiatric rating scale (nursing modification) — an assessment procedure for the nursing team in clinical and research settings. Comprehensive Psychiatry, 29(6), 575-587. doi: 10.1016/0010-440X(88)90078-8

Morlan, K. K., & Tan, S. Y. (1998). Comparison of the Brief Psychiatric Rating Scale and the Brief Symptom Inventory. Journal of Clinical Psychology, 54(7), 885-894. doi: 10.1002/(SICI)1097-4679(199811)54:7<885::AID-JCLP3>3.0.CO;2-E

Overall, J. E., & Gorham, D. R. (1962). The Brief Psychiatric Rating Scale. Psychological Reports, 10(3), 799-812. doi: 10.2466/pr0.1962.10.3.799

van Beek, J., Vuijk, P. J., Harte, J. M., Smit, B. L., Nijman, H., & Scherder, E. J. (2015). The factor structure of the Brief Psychiatric Rating Scale (expanded version) in a sample of forensic psychiatric patients. International Journal of Offender Therapy and Comparative Criminology, 59(7), 743-756. doi: 10.1177/0306624×14529077