Validation of the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC) in a naturalistic sample of 278 patients with acute psychosis and agitation in a psychiatric emergency room

Alonso Montoya, Amparo Valladares, Luis Lizán, Luis San, Rodrigo Escobar, Silvia Paz, Alonso Montoya, Amparo Valladares, Luis Lizán, Luis San, Rodrigo Escobar, Silvia Paz

Abstract

Background: Despite the wide use of the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC) in a clinical setting to assess agitated patients, a validation study to evaluate its psychometric properties was missing.

Methods: Data from the observational NATURA study were used. This research describes trends in the use of treatments in patients with acute psychotic episodes and agitation seen in emergency departments. Exploratory principal component factor analysis was performed. Spearman's correlation and regression analyses (linear regression model) as well as equipercentile linking of Clinical Global Impression of Severity (CGI-S), Agitation and Calmness Evaluation Scale (ACES) and PANSS-EC items were conducted to examine the scale's diagnostic validity. Furthermore, reliability (Cronbach's alpha) and responsiveness were evaluated.

Results: Factor analysis resulted in one factor being retained according to eigenvalue ≥1. At admission, the PANSS-EC and CGI-S were found to be linearly related, with an average increase of 3.4 points (p < 0.001) on the PANSS-EC for each additional CGI-S point. The PANSS-EC and ACES were found to be linearly and inversely related, with an average decrease of 5.5 points (p < 0.001) on the PANSS-EC for each additional point. The equipercentile method shows the poor sensitivity of the ACES scale. Cronbach's alpha was 0.86 and effect size was 1.44.

Conclusions: The factorial analyses confirm the unifactorial structure of the PANSS-EC subscale. The PANSS-EC showed a strong linear correlation with rating scales such as CGI-S and ACES. PANSS-EC has also shown an excellent capacity to detect real changes in agitated patients.

Figures

Figure 1
Figure 1
a. Distribution of the PANSS-EC total scores at patient's admission corresponding to CGI-S values for all patients (unadjusted data). Box = 25% and 75% quartiles, line = median, whiskers = minimum and maximum values, circles = outliers. Note: no participants gave a score of 1 in the CGI-S at admission. PANSS-EC: Excited Component of the Positive and Negative Syndrome Scale; CGI-S: Clinical Global Impression of Severity. b. Distribution of the PANSS-EC total scores at patient's admission corresponding to ACES values for all patients (unadjusted data). Box = 25% and 75% quartiles, line = median, whiskers = minimum and maximum values, circles = outliers. PANSS-EC: Excited Component of the Positive and Negative Syndrome Scale; ACES: Agitation and Calmness Evaluation Scale.
Figure 2
Figure 2
a. Linking of CGI-S with the PANSS-EC score at admission (green line) and at discharge (blue line). The graph plots the corresponding (real) CGI score for every (integer) PANSS-EC score. For the reverse direction, the intersection of the lines indicates an integer CGI value with the graph providing the corresponding PANSS-EC score. PANSS-EC: Excited Component of the Positive and Negative Syndrome Scale; CGI-S: Clinical Global Impression of Severity. b. Linking of ACES with the PANSS-EC score at admission (blue line) and at discharge (green line). The graph plots the corresponding (real) ACES score for every (integer) PANSS-EC score. For the reverse direction, the intersection of the lines indicates an integer ACES value with the graph providing the corresponding PANSS-EC score. PANSS-EC: Excited Component of the Positive and Negative Syndrome Scale; CGI-S: Clinical Global Impression of Severity.
Figure 3
Figure 3
Distribution of the percentage of reduction in the PANSS-EC score corresponding to CGI-I values from baseline to discharge for all patients (unadjusted data). Box = 25% and 75% quartiles, line = median, whiskers = minimum and maximum values, circles = outliers. PANSS-EC: Excited Component of the Positive and Negative Syndrome Scale; CGI-S: Clinical Global Impression of Severity.

References

    1. Allen MH, Currier GW, Hughes DH, Reyes-Harde M, Docherty JP. Expert Consensus Panel for Behavioral Emergencies, 2001. The Expert Consensus Guidelines Series. Treatment of behavioural emergencies. Postgraduate Medicine. 2001. pp. 1–88. quiz 89-90.
    1. Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP. Expert Consensus Panel for Behavioral Emergencies, 2005. The expert consensus guideline series. Treatment of behavioral emergencies. Journal of Psychiatric Practice. 2005;11:5–108. doi: 10.1097/00131746-200511001-00002.
    1. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin. 1987;13:261–276.
    1. Emsley R, Rabinowitz J, Torreman M. RIS-INT-35 Early Psychosis Global Working Group. The factor structure for the Positive and Negative Syndrome Scale (PANSS) in recent-onset psychosis. Schizophrenia Research. 2003;61:47–57. doi: 10.1016/S0920-9964(02)00302-X.
    1. Van den Oord EJ, Rujescu D, Robles JR, Gieling I, Birrell C, Bukszár J. et al.Factor structure and external validity of the PANSS revisited. Schizophrenia Research. 2006;82:213–223. doi: 10.1016/j.schres.2005.09.002.
    1. Lindenmayer JP, Bossie CA, Kujawa M, Zhu Y, Canuso CM. Dimensions of psychosis in patients with bipolar mania as measured by the positive and negative syndrome scale. Psychopathology. 2008;4:264–270. doi: 10.1159/000128325.
    1. Baker RW, Kinon BJ, Maguire GA, Liu H, Hill AL. Effectiveness of rapid initial dose escalation of up to forty milligrams per day of oral olanzapine in acute agitation. Journal of Clinical Psychopharmacology. 2003;23:342–348. doi: 10.1097/01.jcp.0000085406.08426.a8.
    1. Barzman DH, DelBello MP, Adler CM, Stanford KE, Strakowski SM. The efficacy and tolerability of quetiapine versus divalproex for the treatment of impulsivity and reactive aggression in adolescents with co-occurring bipolar disorder and disruptive behavior disorder(s) Journal of Child and Adolescent Psychopharmacology. 2006;16:665–670. doi: 10.1089/cap.2006.16.665.
    1. Currier GW, Trenton AJ, Walsh PG, van Wijngaarden E. A pilot, open-label safety study of quetiapine for treatment of moderate psychotic agitation in the emergency setting. Journal of Psychiatric Practice. 2006;12:223–228. doi: 10.1097/00131746-200607000-00004.
    1. Pascual JC, Madre M, Puigdemont D, Oller S, Corripio I, Diaz A. et al.A naturalistic study: 100 consecutive episodes of acute agitation in a psychiatric emergency department. Actas Españolas de Psiquiatría. 2006;34:239–244.
    1. Panjonk F, Holzbach R, Naber D. Comparing the efficacy of atypical antipsychotics in open uncontrolled versus double-blind controlled trials in schizophrenia. Psychopharmacology (Berl.) 2002;162:29–36. doi: 10.1007/s00213-002-1055-9.
    1. Breier A, Meehan K, Birkett M, David S, Ferchland I, Sutton V. et al.A double-blind, placebo-controlled dose-response comparison of intramuscular olanzapine and haloperidol in the treatment of acute agitation in schizophrenia. Archives of General Psychiatry. 2002;59:441–448. doi: 10.1001/archpsyc.59.5.441.
    1. Meehan KM, Wang H, David SR, Nisivoccia JR, Jones B, Beasley CM Jr. et al.Comparison of rapidly acting intramuscular olanzapine, lorazepam, and placebo: a double-blind, randomized study in acutely agitated patients with dementia. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology. 2002;26:494–504. doi: 10.1016/S0893-133X(01)00365-7.
    1. Casey DE, Daniel DG, Wassef AA, Tracy KA, Wozniak P, Sommerville KW. Effect of divalproex combined with olanzapine or risperidone in patients with an acute exacerbation of schizophrenia. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology. 2003;28:182–192. doi: 10.1038/sj.npp.1300023.
    1. Wright P, Meehan K, Birkett M, Lindborg SR, Taylor CC, Morris P. et al.A comparison of the efficacy and safety of olanzapine versus haloperidol during transition from intramuscular to oral therapy. Clinical Therapeutics. 2003;25:1420–1428. doi: 10.1016/S0149-2918(03)80129-7.
    1. San L, Arranz B, Querejeta I, Barrio S, De la Gandara J, Perez V. A naturalistic multicenter study of intramuscular olanzapine in the treatment of acutely agitated manic or schizophrenic patients. European Psychiatry: the Journal of the Association of European Psychiatrists. 2006;21:539–543.
    1. Turczyński J, Bidzan L, Staszewska-Małys E. Olanzapine in the treatment of agitation in hospitalized patients with schizophrenia and schizoaffective and schizofreniform disorders. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research. 2004;10:I74–180.
    1. Zhong KX, Tariot PN, Mintzer J, Minkwitz MC, Devine NA. Quetiapine to treat agitation in dementia: a randomized, double-blind, placebo-controlled study. Current Alzheimer Research. 2007;4:81–93. doi: 10.2174/156720507779939805.
    1. Nordstrom K, Allen MH. Managing the acutely agitated and psychotic patient. CNS Spectrums. 2007;12:5–11.
    1. Montoya A, San L, Olivares JM, Pérez-Sola V, Casillas M, López-Carrero C. et al.Clinical characteristics of agitated psychotic patients treated with an oral antipsychotics attended in the emergency room setting: NATURA study. International Journal of Psychiatry in Clinical Practice. 2008;12:127–133. doi: 10.1080/13651500701749859.
    1. Escobar R, San L, Pérez V, Olivares JM, Polavieja P, López-Carrero C. et al.Effectiveness results of olanzapine in acute psychotic patients with agitation in the emergency room setting: results from NATURA study. Actas Españolas de Psiquiatría. 2008;36:151–157.
    1. Guy W. ECDEU Assessment Manual for Psychopharmacology US Department of Health, Education, and Welfare publication, revised ed. National Institute of Mental Health, Rockville, MD; 1976.
    1. Berk M, Ng F, Dodd S, Callaly T, Campbell S, Bernardo M. et al.The validity of the CGI severity and improvement scales as measures of clinical effectiveness suitable for routine clinical use. Journal of Evaluation in Clinical Practice. 2008;14:979–983. doi: 10.1111/j.1365-2753.2007.00921.x.
    1. Battaglia J, Lindborg SR, Alaka J, Meehan K, Wright P. Calming versus sedative effects of intramuscular olanzapine in agitated patients. The American Journal of Emergency Medicine. 2003;21:192–198. doi: 10.1016/S0735-6757(02)42249-8.
    1. Zumbo BD. In: Handbook of Statistics 26: Psychometrics. Rao CR, Sinharay S, editor. Elsevier, London; 2007. Validity: foundational issues and statistical methodology.
    1. Zumbo BD, (Ed) Special issue of the journal Social Indicators Resesarch: An International and Interdisciplinary Journal for Quality of Life Measurements. 1-3. Vol. 45. Amsterdam: Kluwer Acaddenic Press; 1998. Validity theory and the methods used in validation: perspectives from the social and behavioural sciences; pp. 1–359.
    1. Kolen MJ, Brennan RL. Test Equating, Scaling, and Linking: Methods and Practices. second. New York: Springer-Verlag; 2004.
    1. Holland PW, Dorans NJ. In: Educational Measurement. 4. Brennan RL, editor. Wesport, CT: Praeger Publishers; 2006. Linking and equating.
    1. Dorans NJ, Pommerich M, Holland PW. Linking and aligning scores and scales. New York: Springer; 2007.
    1. Guyatt GH, Walter SD, Norman G. Measuring change over time: assessing the usefulness of evaluative instruments. J Chronic Diseases. 1987;40:171–178. doi: 10.1016/0021-9681(87)90069-5.
    1. Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Medical Care. 1989;27:178–189. doi: 10.1097/00005650-198903001-00015.
    1. Brand A, Bradley MT, Best LA, Stoica G. Accuracy of effect size estimates from published psychological research. Perceptual and Motor Skills. 2008;106:645–649. doi: 10.2466/pms.106.2.645-649.
    1. Steinberg L, Thissen D. Using effect sizes for research reporting: examples using item response theory to analyze differential item functioning. Psychological Methods. 2006;11:402–415. doi: 10.1037/1082-989X.11.4.402.
    1. Cohen J. Statistical power analysis for the behavioural sciences. New York: Academic Press Inc; 1977.
    1. Levine SZ, Rabinowitz J, Engel R, Etschel E, Leucht S. Extrapolation between measures of symptoms severity and change: an examination of the PANSS and CGI. Schizophrenia Research. 2008;98:318–322. doi: 10.1016/j.schres.2007.09.006.
    1. Laenen A, Alonso A, Molenberghs G, Vangeneugden T, Mallinckrodt CH. Using longitudinal data from a clinical trial in depression to assess the reliability of its outcome scales. J Psychiatr Res. 2009;43:730–8. doi: 10.1016/j.jpsychires.2008.09.010.
    1. Alonso A, Laenen A, Molenberghs G, Geys H, Vangeneugden T. A unified approach to multi-item reliability. Biometrics. 2010;66:1061–8. doi: 10.1111/j.1541-0420.2009.01373.x.
    1. Wilhelm S, Schacht A, Wagner T. Use of antipsychotics and benzodiazepines in patients with psychiatric emergencies: results of an observational trial. BMC Psychiatry. 2008;8:61. doi: 10.1186/1471-244X-8-61.
    1. Huber CG, Lambert M, Naber D, Schacht A, Hundemer HP, Wagner TT. et al.Validation of a Clinical Global Impression Scale for Aggression (CGI-A) in a sample of 558 psychiatric patients. Schizophrenia Research. 2008;100:342–348. doi: 10.1016/j.schres.2007.12.480.
    1. Leucht S, Kane JM, Kissling W, Hamann J, Etschel E, Engel RR. What does the PANS mean? Schizophrenia Research. 2005;79:231–238. doi: 10.1016/j.schres.2005.04.008.

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