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Bush-Francis Catatonia Rating Scale (BFCRS) and Screening Instrument (BFCSI)

The BFCRS rates 23 catatonic signs from 0 to 3 (severity 0–69). The screening instrument (BFCSI) is the first 14 items scored present or absent: 2 or more present is a positive screen for catatonia. Track the 23-item severity score serially, e.g. before and after a lorazepam challenge.

  • 1. Immobility/stupor: 0 – Absent (0); 1 – Sits abnormally still, may interact briefly (1); 2 – Virtually no interaction with external world (2); 3 – Stuporous, non-reactive to painful stimuli (3)
  • 2. Mutism: 0 – Absent (0); 1 – Unresponsive to majority of questions; incomprehensible whisper (1); 2 – Speaks <20 words/5 min (2); 3 – No speech (3)
  • 3. Staring: 0 – Absent (0); 1 – Poor eye contact, gazes <20 s; decreased blinking (1); 2 – Gaze held >20 s, occasionally shifts attention (2); 3 – Fixed gaze, non-reactive (3)
  • 4. Posturing/catalepsy: 0 – Absent (0); 1 – <1 min (1); 2 – 1–15 min (2); 3 – Bizarre posture, or mundane maintained >15 min (3)
  • 5. Grimacing: 0 – Absent (0); 1 – <10 s (1); 2 – <1 min (2); 3 – Bizarre expression or maintained >1 min (3)
  • 6. Echopraxia/echolalia: 0 – Absent (0); 1 – Occasional (1); 2 – Frequent (2); 3 – Constant (3)
  • 7. Stereotypy: 0 – Absent (0); 1 – Occasional (1); 2 – Frequent (2); 3 – Constant (3)
  • 8. Mannerisms: 0 – Absent (0); 1 – Occasional (1); 2 – Frequent (2); 3 – Constant (3)
  • 9. Verbigeration: 0 – Absent (0); 1 – Occasional (1); 2 – Frequent, difficult to interrupt (2); 3 – Constant (3)
  • 10. Rigidity: 0 – Absent (0); 1 – Mild resistance (1); 2 – Moderate (2); 3 – Severe, cannot be repostured (3)
  • 11. Negativism: 0 – Absent (0); 1 – Mild resistance and/or occasionally contrary (1); 2 – Moderate resistance and/or frequently contrary (2); 3 – Severe resistance and/or continually contrary (3)
  • 12. Waxy flexibility: 0 – Absent (0); 3 – Present (3)
  • 13. Withdrawal (refusal to eat, drink, make eye contact): 0 – Absent (0); 1 – Minimal intake/interaction <1 day (1); 2 – Minimal intake/interaction >1 day (2); 3 – No intake/interaction ≥1 day (3)
  • 14. Excitement: 0 – Absent (0); 1 – Excessive motion, intermittent (1); 2 – Constant motion, hyperkinetic without rest (2); 3 – Full-blown catatonic excitement, endless frenzied activity (3)
  • 15. Impulsivity: 0 – Absent (0); 1 – Occasional (1); 2 – Frequent (2); 3 – Constant or not redirectable (3)
  • 16. Automatic obedience: 0 – Absent (0); 1 – Occasional (1); 2 – Frequent (2); 3 – Constant (3)
  • 17. Mitgehen (passive obedience): 0 – Absent (0); 3 – Present (3)
  • 18. Gegenhalten (muscle resistance): 0 – Absent (0); 3 – Present (3)
  • 19. Ambitendency (motorically stuck): 0 – Absent (0); 3 – Present (3)
  • 20. Grasp reflex: 0 – Absent (0); 3 – Present (3)
  • 21. Perseveration: 0 – Absent (0); 3 – Present (3)
  • 22. Combativeness: 0 – Absent (0); 1 – Occasionally strikes out, low injury potential (1); 2 – Frequently strikes out, moderate injury potential (2); 3 – Serious danger to others (3)
  • 23. Autonomic abnormality (temperature, BP, pulse, RR, sweating): 0 – Absent (0); 1 – Abnormality of one parameter (exclude pre-existing hypertension) (1); 2 – Abnormality of two parameters (2); 3 – Abnormality of three or more parameters (3)
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Interpretation

ResultMeaning
BFCSI ≥ 2 of items 1–14Positive screen: complete full BFCRS, consider lorazepam challenge
BFCSI 0–1Negative screen
Severity 0–69Higher = more severe; track serially

Formula

Severity = sum of 23 items, each 0–3 (items waxy flexibility, mitgehen, gegenhalten, ambitendency, grasp reflex and perseveration are 0 or 3 only). Screen = number of items 1–14 rated present; ≥2 = positive.

Clinical pearls

  • Rate only items that are clearly present; if uncertain, rate 0 (scale instructions). Unrated items here default to 0.
  • Screening item order follows the published form: immobility, mutism, staring, posturing, grimacing, echophenomena, stereotypy, mannerisms, verbigeration, rigidity, negativism, waxy flexibility, withdrawal, excitement.
  • A ≥50% fall in severity after IV lorazepam 1–2 mg supports the diagnosis; exclude NMS (rigidity + fever + autonomic instability) before antipsychotics.

Examples

bush francis mutism 3, staring 2, immobility 2, posturing 1, negativism 2catatonia screen: mute, fixed gaze, waxy flexibility presentbfcrs withdrawal 3 rigidity 2 grasp reflex present autonomic 1

FAQ

How many Bush-Francis items are needed to diagnose catatonia?

Two or more of the first 14 items (the Bush-Francis Catatonia Screening Instrument) present is a positive screen. DSM-5 requires 3 of 12 specified signs.

What is the maximum BFCRS score?

69 (23 items × 3). The total is used to track severity and treatment response rather than as a diagnostic cut-off.

Evidence

  1. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand 1996;93:129–36.

Psychiatry & Substance Use · Reviewed 2026-10-14 · Methodology