Reducing guesswork in schizophrenia treatment

The Positive and Negative Syndrome Scale (PANSS) is moving from research into clinical practice as demand grows for objective rating scales. We see the PANSS becoming a treatment and planning tool for psychiatry, just as the electrocardiogram evolved into a measure of cardiac status in medical practice.

Based on our experience in co-authoring (LA Opler) and using the PANSS, we describe how you can use it to:

• identify psychotic symptoms for targeted treatment
  
• predict with greater accuracy how patients will respond to the treatment you provide.
  

Standardized Assessments

The PANSS first gained stature in studies that established the efficacy of second-generation antipsychotics (SGAs).^1-6 But its authors⁷ also envisioned the scale as a useful tool to help practicing clinicians treat patients with schizophrenia and other psychotic disorders.

Twenty years of experience has shown the PANSS to be a reliable and valid severity symptom scale for schizophrenia, bipolar disorder, and other serious mental illnesses. It is particularly useful to track changes in positive and negative symptoms.⁸

Traditionally, psychiatric evaluation has been impressionistic and subjective, but standardized tools provide a common language while introducing objective, empiric measures of clinical status. Because patients with mental disorders are treated by providers from psychiatry, psychology, social work, nursing, and other mental health disciplines, having standardized benchmarks to assess symptom severity can facilitate an integrated approach. And because the PANSS has been translated into some 40 languages and is being adopted in clinical settings worldwide, it provides a universal means of communicating information about a patient’s clinical status.

Panss Scoring System

The PANSS includes 30 items, each rated from 1 (absent) to 7 (extreme). In theory, a patient rated “absent” (or 1) on all items would receive a total score of 30, and a patient rated “extreme” (or 7) on all items would receive a total score of 210. In the real world, though, no one sees these extremes. Stable outpatients usually score 60 to 80. Inpatients’ scores rarely exceed 80 to 150, even in “treatment refractory” cases.

The 30 items are arranged as 7 positive symptom subscale items (P1-P7), 7 negative symptom subscale items (N1-N7), and 16 general psychopathology symptom items (G1-G16) (Table 1). Each item has a definition and a basis for rating. The first question you need to answer when rating a patient is whether the item is absent or present.

How it works. For example, the PANSS defines delusions as “beliefs that are unfounded, unrealistic, and idiosyncratic,” and the basis for rating is “thought content expressed during the interview and its influence on the patient’s social relations and behavior as reported from primary care workers or family.” If the definition does not apply to your patient, you rate this item 1 or absent. If the definition does apply, “anchoring points” for each level of severity are provided (Table 2), and you decide which anchoring point best describes the patient’s functioning during the interview and the preceding week.

Time required. In research, gathering informant information, conducting the interview, and generating reliable ratings takes 45 to 60 minutes. In clinical settings, if you know your patient and can function as informant and interviewer, you probably can obtain accurate ratings in 30 to 45 minutes.

Ideally, you would use the Structured Clinical Interview for the PANSS (SCI-PANSS), though clinicians who know this instrument well may prefer a less structured interview that covers all areas of inquiry. Accurate PANSS scores are easy to generate on all 30 items by combining information from the interview with information about how the patient has functioned in the past week.

PANSS ratings are not meant to be obtained after every patient contact but rather as often as needed to guide clinical treatment. For example, you might obtain a PANSS rating:

• when an inpatient is first admitted
  
• before starting a new medication
  
• weeks or months later to gauge the new treatment’s effect.
  

The PANSS manual—a complete individual kit costs approximately $200—or licenses to use multiple copies are available from the copyright holder, MultiHealth Systems, Inc. (see Related resources).

Table 1

Subscales of the 30-item Positive and Negative Syndrome Scale (PANSS)