Evidence-Based Reviews

Reducing guesswork in schizophrenia treatment

Current Psychiatry. 2006 September;5(9):76-84

References

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Table 2

7 levels of severity on the PANSS for characterizing delusions

Severity level (“anchoring point”)	Description of patient function
1 - Absent	The definition does not apply
2 - Minimal	Questionable pathology; the patient may be at the upper extreme of normal limits
3 - Mild	Presence of one or two delusions that are vague, uncrystallized, and not tenaciously held. The delusions do not interfere with the patient’s thinking, social relations, or behavior
4 - Moderate	Presence of either a kaleidoscopic array of poorly formed, unstable delusions, or a few well-formed delusions that occasionally interfere with the patient’s thinking, social relations, or behavior
5 - Moderate severe	Presence of numerous well-formed delusions that are tenaciously held and occasionally interfere with the patient’s thinking, social relations, or behavior
6 - Severe	Presence of a stable set of delusions that are crystallized, possibly systematized, tenaciously held, and clearly interfere with the patient’s thinking, social relations, or behavior
7 - Extreme	Presence of a stable set of delusions that are either highly systematized or very numerous, and that dominate major facets of the patient’s life. This behavior frequently results in inappropriate and irresponsible action that may jeopardize the safety of the patient or others

Gauging Symptom Severity

Treatment planning. Clinicians at the Rochester (New York) Psychiatric Center use the PANSS to assess symptom severity in inpatients with schizophrenia and other psychotic disorders.

Within 1 week of admission, patients are evaluated on the 30 items by a team of experienced PANSS raters. Symptoms identified by the PANSS become targets in individualized treatment plans. Follow-up PANSS assessments help determine if treatment has improved the selected symptoms.

Tracking patient progress. Florida State Hospital uses the PANSS to track progress of patients with serious mental illnesses. Data collected over 8 years from >19,000 PANSS assessments in a multilingual, multicultural population suggests that the PANSS:

aids in decision making for medical and nonmedical aspects of care for individual patients
can help determine if changes in agency prescribing practices affect patient symptom profiles and severity, one indicator of how policy and guidelines translate into patient care.⁹

Monitoring depression. In Geha Psychiatric Hospital in Tel Aviv, Israel, treatment outcomes improved when the PANSS was used to measure severity of symptoms—particularly depression—in an inpatient population of adolescents with schizophrenia.¹⁰ PANSS items can measure dysphoria, including anxiety, tension, and guilt feelings. Clinicians now routinely use the PANSS to assess patients’ symptoms at admission and for periodic follow-up.

Predicting Outcomes

The PANSS has been shown to predict course of illness and treatment response, functional outcomes (including aggression), and long-term outcomes (including deterioration). Adjusting treatments to achieve optimal PANSS scores also can help clinicians achieve remission of their patients’ psychotic symptoms (Box).^11,12

Box

Other PANSS uses: Define remission, predict treatment costs

Remission. Achieving and maintaining remission of schizophrenia has been hampered by a lack of specificity in existing scales. Andreasen et al¹¹ recommend using selected items from the PANSS and other rating scales, including the Brief Psychiatric Rating Scale (BPRS), Scale for Assessment of Negative Symptoms (SANS), and Scale for Assessment of Positive Symptoms (SAPS).

Creating agreed-upon criteria will mean that clinicians will know what is meant by symptom remission, allowing for better communication and a standard to achieve.

Costs. Eventually, rating scales such as PANSS may provide “financial prognoses” to predict treatment costs over time. Mohr et al¹² used PANSS scores to group 663 patients from public and private psychiatric hospitals into eight categories based on symptom severity. When each disease state was correlated with annual treatment costs, baseline assessment was a significant predictor of annualized cost as well as clinical outcome.

Course of illness. Schizophrenia patients in a Tokyo hospital psychiatric ward were rated within 3 days of admission and at weekly intervals for 8 weeks. Baseline PANSS scores on the conceptual disorganization item and the total negative scale score predicted which patients would respond to antipsychotic treatment within 5 weeks.¹³

Functional outcomes. Steinert et al¹⁴ used the PANSS to rate 199 inpatients within 24 hours of admission into an acute psychiatric ward. After discharge, each patient was assessed retrospectively for aggressive behavior. The conceptual disorganization and hostility items from the positive sub-scale could predict violent behaviors during inpatient treatment with statistical significance.

Long-term outcomes. White et al¹⁵ assessed older schizophrenia inpatients, using the PANSS at baseline and after 1 year. The researchers looked specifically at the “activation factor”—six PANSS items including hostility, poor impulse control, excitement, uncooperativeness, poor rapport, and tension. Poor outcome and low discharge rates were directly correlated with high baseline scores on the PANSS activation factor (PANSS-AF).

Deterioration. Goetz et al¹⁶ showed that residual positive symptoms were significantly related to deteriorating course of illness, even when patients adhered to their medications. These results suggest that even subtle symptom elevations as measured by the PANSS can predict deterioration.