BISS Bowden

Bipolar Inventory of Signs and Symptoms Scale (BISS)

General Instructions
Items are scored from 0 to 4, based on the most recent 7 day period, utilizing information from self report, and family and clinician observation both outside
and during the interview. The anchor statements are examples of behaviors, proportions of time experiencing disturbance, severity of disturbance, and functional
impairment that would qualify for a specific score, but do not exclude similar behaviors and internal feelings that would qualify for that score. Items are scored
both on the basis of frequency and severity. A score of 3, in most cases, also entails behavior that is observable to others. A score of 0 means the symptom is
completely absent. When in doubt between 2 ratings, assign the higher score. Some items in the mania section, e.g. No. 26, Hyperactive, rate behavior that may
not have associated impairment of function or adverse consequences. For each defined item, please ask the bolded questions as they are written, or nearly so,
for purposes of increasing the consistency of patient responses. The questions in italics are to be asked only if the patient indicates some symptomatology on the
bolded general question(s) for the item. Additional questions to those in italics may be needed to establish item severity for individual patients. Rate each item
independently. For example, a patient could have both psychomotor slowing (9) and agitation (22) if the behaviors occurred at different times over the rating
period. When asking the questions for the item at the top of each page, start with the phrase, “Over the past week have…”
The Scale lists depressive symptoms first. If the patient is known, or the primary problem area already identified, we recommend commencing the interview
with the area of prominent symptomatology and concern to the patient, then completing all remaining sections.
I. DEPRESSION
  1. Sadness-reported: Subjective feeling of depression based on verbal 0 Not at all
complaints of feeling depressed, sad, blue, gloomy, down in the 1 Slight; e.g., only occasionally feels “sad” or “down”
dumps, empty, “don’t care.” Do not include such ideational aspects as
discouragement, pessimism, or worthlessness; suicide attempts or 2 Mild; e.g., often feels somewhat “depressed,” “blue” or “downhearted,”
depressed appearance or suicide attempts. and/or appears sad and is less responsive to positive stimulus
During the past 7 days, how have you been feeling? 3 Moderate; e.g., most of the time feels “depressed,” and/or several
Describe your mood? manifestations of sadness with limited ability to brighten up
Have you felt depressed (sad, blue, moody, down, empty, 4 Severe; e.g., most of the time feels “wretched,” sustained gloomy
as if you didn’t care)? appearance
Have you cried or been tearful? How often? Does it come and go?
How long does it last? How bad is the feeling? Can you stand it?

  2. Sadness-observed: Appears despondent, gloomy, despairing, as 0 Not at all

reflected in speech, facial expression, and posture. Rate also by inability 1 Slight; e.g., looks dispirited, but brightens up easily
to brighten up.
2 Mild; e.g., more physical manifestations of sadness, and less response to
Have others commented that you appeared sad, blue, or unhappy? positive stimulus
3 Moderate; e.g., often appears sad and unhappy
3 Severe; e.g., extreme and continuous gloom and despondency

  3. Pessimism: Discouragement, pessimism and hopelessness. 0 Not at all

Have you been discouraged (pessimistic, felt hopeless)? 1 Slight; e.g., occasional feelings of discouragement about future
What kind of future do you see for yourself? 2 Mild; e.g., often somewhat discouraged
How do you think things will work out? 3 Moderate; e.g., very often feels quite pessimistic about the future
Can you see yourself or your situation getting any better?
4 Severe; e.g., pervasive feelings of intense pessimism

  4. Suicidality: Suicidal tendencies, including preoccupation with thoughts of 0 Not at all

death or suicide. Do not include mere fears of dying. 1 Slight; e.g., occasional thoughts of death (without suicidal thoughts),
When a person gets upset, depressed, or feels hopeless, he or she “I would be better off dead” or “I wish I were dead.”
may think about dying or even killing themselves. Have you had any 2 Mild; e.g., frequent thoughts of being better off dead or occasional
such thoughts? thoughts of suicide but has no plan or intent
Have you thought about how you would do it? 3 Moderate; e.g. often thinks of suicide or has thought of a specific method
Have you told anybody about suicidal thoughts?
Have you actually done anything? 4 Severe; e.g. often thinks of suicide and has thought of a specific plan or
has made a suicidal gesture or attempt

  5. Worry: Worrying, brooding, painful preoccupation and inability to get 0 Not at all
mind off unpleasant thoughts (may or may not be accompanied by 1 Slight; e.g., occasionally worries about some realistic or trivial problem
depressive mood).
2 Mild; e.g., often worries excessively about a problem
Have you been worrying a lot?
3 Moderate; e.g., very often worries excessively about a realistic or trivial
How much do you worry? What kinds of things have you been worrying about? problem
How much of your time is spent in this?
Are you able to get your mind off it? 4 Severe; e.g., most of the time is spent in worrying or brooding about
problems which he/she cannot dispel

  6. Guilt: Feelings of self-reproach or excessive, inappropriate guilt for things 0 Not at all
done or not done. 1 Slight; e.g., occasional feelings of mild self-blame
Do you blame yourself for anything you have done or not done? 2 Mild; e.g., often feels somewhat guilty about past actions, the significance
What about feeling guilty? of which are exaggerated, such as consequences of the illness
Do you feel you have done anything wrong?
3 Moderate; e.g., often feels quite guilty about past actions or feelings of
Do you deserve punishment? guilt that cannot be explained
Do you feel you have brought this on yourself?
Have you been critical of yourself? 4 Severe; e.g., pervasive feelings of intense guilt, self-reproach or generalizes
feelings of self-blame

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  7. Feelings of inadequacy: Negative evaluation of him or herself, including 0 Not at all

feelings of inadequacy, failure, worthlessness. 1 Slight; e.g., occasional feelings of inadequacy
How has your self-esteem been this past week? 2 Mild; e.g., often feels somewhat inadequate
Are you down on yourself?
What is your opinion of yourself compared to other people? 3 Moderate; e.g., often feels like a failure
Worthless? A failure? How often do you feel this way about yourself? 4 Severe; e.g., pervasive feelings of worthlessness

  8. Low energy: Difficulty getting started, or slowness initiating and 0 Not at all
performing everyday activities. Subjective feeling of lack of energy or 1 Slight; e.g., occasional less energy than usual
fatigue. Do not rate lack of interest.
2 Mild; e.g., at times definitely more tired, or less energy than usual
Have you had less energy than usual to do things? Have you been
getting tired easily? I am not talking about your interest in things, but 3 Moderate; e.g., most of time is very tired, lacking energy
your physical energy to do things. 4 Severe; e.g., spends most of time resting, nearly always feels fatigued
Has this interfered with your accomplishing tasks that you ordinarily need to
do? Have you needed help in getting started?

  9. Psychomotor slowing: Generalized slowing down of physical reactions, 0 Not at all

movements, and speech, including latency in speech. Rate both on 1 Slight, of doubtful clinical significance, only subjective feeling of
observed and reported information. being slowed
Have you been slowed down, not able to move as quickly as usual? 2 Mild; e.g., conversation is noticeably retarded but not strained
Did you find it hard to start talking? 3 Moderate; e.g., conversation is strained, or moves very slowly
Did you talk a lot less than usual?
Did you feel like you were moving in slow motion? 4 Severe; e.g., conversation is difficult to maintain, or hardly moves at all

10. Loss of interest: Subjective experience of reduced interest in the 0 Not at all
surroundings, or activities that normally give pleasure. Reduced ability to 1 Slightly reduced ability to enjoy usual interests. Reduced ability to feel
react with adequate emotion to circumstances or people anger
When you participated in activities that you usually enjoy, were they 2 Mild; e.g., loss of interest in the surroundings/activities, loss of feelings for
pleasurable for you? friends and acquaintances
If you did not do any of your usual activities, was this because you did
not have the opportunity? (If the answer is opportunity, do not rate 3 Moderate; e.g., most of the time has moderately reduced interest in most
towards loss of interest.) pleasurable activities
Can you experience your usual feelings for your loved ones? 4 Severe; e.g., feels emotionally paralyzed, inability to feel anger or grief, and
a complete or even painful failure to feel for close relatives and friends

11. Social withdrawal: Reduced interest in and attention to others. Associated 0 Not at all
with reduced social interactions, and reduced time spent with others. 1 Slight reduction in interest in social interaction
Have you had less interest in spending time with other people, including 2 Mild; e.g., actual reduction in social interaction, associated with some
your family members, friends, or persons you work with? avoidance of others
Did you actually spend less time interacting with others?
3 Moderate; e.g., substantially reduced time spent with others, with some
How much less time than usual for you does this represent? adverse consequences to the social avoidance
Did you avoid social contact with people whom you normally interact with?
4 Marked reduction in social interactions, with consequent difficulties in
relationships with family, friends, peers

12. Reduced sex drive: Reduced sexual interest, fantasies, or a reduction of 0 Not at all
sexual activity. Judge against the subject’s usual sexual interests and habits 1 Slight; sexual interest is reduced
when well.
2 Mild; e.g., definite reduction of sexual interest. Usual sexual activities
What has your sexual interest and activity been like this past week? partially reduced
Has it been reduced at any time?
3 Moderate; e.g., persistent reduction of sexual interest. Usual sexual
Can you tell me an example of the way it has changed, been low? activities reduced consistently
4 Severe; e.g., complete sexual indifference. “I have no interest in sex.”

13. Anxiety-reported: Subjective feelings of anxiety, fearfulness, or 0 Not at all

apprehension, whether or not accompanied by somatic anxiety and 1 Slight; e.g., fleeting inner tension
whether focused on specific concerns or not.
2 Mild; e.g., periods of tension, fear that can be mastered
Have you felt tense or anxious?
3 Moderate; e.g., tense, ill at ease most of the time, minimal ability to control
Does this get to the point that you feel uncomfortable? tension, fear
Have you had anxiety attacks?
Are you able to control these feelings? 4 Severe; e.g., tense, fearful, frequent anxiety attacks. Often functionally
incapacitating

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14. Anxiety-observed: Autonomic over-activity and/or muscle tension, 0 Not at all

expressed in facial appearance, flushing, sweating, cold hands, posture, 1 Slight; occasional or slight autonomic disturbances such as flushing or
movements. sweating under stress
Over the past week have others commented that you appeared tense or 2 Mild; e.g., autonomic disturbance on several occasions, even when not
showed signs of anxiety, such as sweating or clammy hands? under stress
3 Moderate; e.g., tense, ill at ease most of the time, minimal ability to control
tension, fear
4 Severe; e.g., tense, fearful, frequent anxiety attacks. Often functionally
incapacitating.

15. Somatic anxiety-reported: Has been bothered by 1 or more physiological 0 Not at all
concomitants of anxiety. 1 Slight; e.g., occasionally palms sweat excessively
Have you been bothered by physical symptoms like palpitations, 2 Mild; e.g., often has 1 or more physical symptoms to a mild degree
shortness of breath, sweating, headaches, stomach cramps, diarrhea or
muscle tension? 3 Moderate; e.g., often has several symptoms or 1 symptom to a
considerable degree
If yes, determine if there were other symptoms and the overall severity of
the disturbance. 4 Severe; e.g., very frequently bothered by 1 or more symptoms or
1 symptom to a severe degree

16. Fearfulness. Alerting response associated with perceived unfamiliar or 0 Not at all
threatening sound, visualization, event or smell, coupled with autonomic 1 Slight, occasional feelings of fear that quickly abate
arousal (increased pulse, heavy breathing), impulse to retreat or attack.
2 Mild, e.g.; occasional fear that persists despite efforts to control
Some people feel frightened easily when unpleasant events take place
around them. Has that happened to you in the past week? 3 Moderate, e.g., fearful most days, sometimes associated with retreating or
What about feeling frightened unexpectedly? hostile reaction
Has the degree that you have been frightened been more than when 4 Severe, e.g.; quite fearful most days, much of day. Unable to control fear, or
you are feeling well? at least one intensely fearful experience.
How have you felt inside when this has happened?
How well have you been able to control the fear?

17. Insomnia. Sleep disturbance, including initial, middle and terminal 0 No experience of insomnia during rating period
difficulty in getting to sleep or staying asleep or waking up earlier 1 Slight; e.g., occasional difficulty with insomnia.
than usual. Take into account the estimated number of hours slept and
subjective sense of lost sleep. Do not rate decreased need for sleep. 2 Mild; e.g., often has some significant difficulty
Are you taking any medication to help you sleep? 3 Moderate; e.g., usually has considerable difficulty
How has your sleep been this last week? 4 Severe; e.g., almost always has great difficulty
Did you have any difficulty getting to sleep? How many hours a night
were you able to sleep even when tired?
How many days did you have difficulty sleeping?
How does that compare with a usual full night of sleep for you?

18. Excessive sleep. Increased duration of sleep, compared to the subject’s 0 No excessive sleep during this period
own normal pattern when well. The questions for item 17 will aid in rating 1 Slight; sleeps longer than usual 1-2 nights/week
this item. It is possible that a patient could receive a positive score for both
item 17 and 18. Rate independent of whether person is taking a drug that 2 Mild; sleeps 2-3 hours extra most days
might alter sleep. 3 Moderate; e.g., spends part of day asleep in spite of normal or increased
During the past week, have you overslept in the morning? sleep at night
Do you take naps during the day? 4 Severe; sleep increased by 4 or more hours, difficulty getting out of bed,
Do you ever have difficulty getting out of bed? despite excessive duration of sleep
How many more hours sleep have you been getting than usual?

19. Reduced appetite: Appetite compared to usual. 0 No change at all

Has your appetite for food changed in the last week compared to the 1 Slight decrease, questionable clinical significance
way it usually is? 2 Mild decrease in appetite
Have you eaten less than you usually do?
Do you have to force yourself to eat? 3 Moderate decrease in appetite associated with change in weight
Do other people have to urge you to eat? 4 Severe loss of appetite, e.g., no appetite, significant weight loss
Over the past month, has your weight changed?
By how much?

20. Increased appetite: Increase in appetite and/or binge eating. 0 Not at all
Have you eaten more than you usually do? 1 Slight increase, questionable clinical significance
Are you able to control how much you eat? 2 Mild increase in appetite
Have you binged on any foods?
Have you eaten snacks between regular meals? 3 Moderate loss of control over eating and/or increase in appetite associated
with change in weight
Appetite associated with change in weight?
How much of the time have you binged, eaten snacks, etc? 4 Severe increase (loss of control over eating or significant weight gain)

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21. Impaired concentration: Difficulty in collecting one’s thoughts, mounting 0 Not at all
to incapacitating lack of concentration. Rate frequency, intensity and 1 Slight; e.g., occasional difficulties in collecting one’s thoughts
degree of incapacity produced.
2 Mild; e.g., difficulties in concentrating and sustaining thought, which at
How well have you been able to concentrate? times interferes with reading or conversation
Are there any times when your concentration has been below your
normal level? 3 Moderate; e.g., most of time has impaired concentration, and usual
responsibilities and actions are hampered by this
Has this interfered with your reading, work, making conversation with others?
4 Severe; e.g., incapacitating lack of concentration

22. Agitation: Purposeless motor activity. Inability to sit still, pacing, fidgeting, 0 Not at all
wringing hands, pulling at clothes, movement of lips or fingers. Do not 1 Slight, and of doubtful clinical significance
include feeling of tension or restlessness. Rate observed and reported
behavior. 2 Mild; e.g., occasionally fidgety or unable to sit quietly in a chair
Were there times when you were unable to sit still? Did you feel like you 3 Moderate; e.g., often pulling at hair, clothing, etc or having to move
had to be constantly pacing up and down? 4 Severe; e.g., constantly fidgety or pulling at hair, clothing, etc or pacing up
Did you notice that you were pulling on your clothing, hair, or skin? Did you and down
wring your hands? How frequently did you do this? Did it cause you any
difficulties in the way you functioned?
II. MANIA
23. Irritability-reported: Subjective feeling of anger, resentment, or 0 Not at all
annoyance (directed externally) whether expressed overtly or not. Rate 1 Slight and of doubtful clinical significance
only the intensity and duration of the subjective sense of irritability.
2 Mild; e.g., definitely more irritable than called for by the situation but only
How irritated, angry, or resentful have you felt—whether you showed it occasional and not intense
or not?
3 Moderate; e.g., often feelings quite angry or occasionally feels very angry
How strongly did you feel this way? How much of the time did you
feel this way? How did you show your (anger, annoyance, irritability)? 4 Severe; e.g., most of the time quite angry or often feels very angry

24. Irritability-observed: Overt expression of irritability, annoyance and anger. 0 Not at all
Do not rate subjective feelings of annoyance, anger, or irritability on this 1 Slight and of doubtful clinical significance
item, no matter how intense, unless it is expressed overtly. Include any
irritability observed by others. 2 Mild; e.g., definitely more irritable than called for by the situation but only
occasional and not intense
Over the past week, have you expressed your irritation or
anger to others? 3 Moderate; e.g., often displays anger
How often did that occur? 4 Severe; e.g., most of the time displays intense anger

25. Aggressive behavior: confrontational, argumentative behavior. 0 Not at all

During the past week, have there been any times when you were loud, 1 Slight and of doubtful clinical significance
demanding, or sarcastic? 2 Mild; e.g., loud, sarcastic, at times, but only occasionally
Did you have any arguments or confrontations with people?
3 Moderate; e.g., often demanding or loud
Did you lose your temper when the above occurred? Did you throw or break
anything? Did you push or hit anyone? 4 Severe; e.g., most of time somewhat demanding, loud, or any episode of
shouting, hitting, breaking

26. Hyperactive: Increase in goal-directed activity as compared with usual 0 Not at all
level. Consider changes in involvement or activity level associated 1 Slightly more interest in activities, but of questionable significance
with work, family, friends, sex drive, projects, interests or activities
(e.g., telephone calls, letter writing). 2 Mild increase in activity level
Have you been more active or involved in things than usual? 3 Moderate increase in activity
What about your work, housekeeping, family, friends, sex, hobbies, new 4 Marked increase, almost constantly involved in numerous activities in
projects or interests? How much of your day has been spent on this? many areas

27. Energetic: Unusually energetic, more active than the usual level without 0 Not at all
expected fatigue. 1 Slightly more energetic but of questionable significance
Have you had more energy than usual to do things? 2 Mild increase in energy. Less fatigued than usual.
More than just a return to normal or usual level? 3 Moderate increase in energy compared to usual, with little or no fatigue
Did it seem like too much energy?
4 Markedly more energetic than usual, all or nearly all of time, with little or
no fatigue

28. Increased social interest: Increased interest in, attention to others. 0 Not at all
Associated with increased social interactions and time spent with others. 1 Slight increase in interest in social interaction.
Have you had more interest than usual in spending time with other 2 Mild; actual increase in social interaction, associated with actively seeking
people, including church, family, friends, co-workers? out others
Did you actually spend more time interacting with others? 3 Moderate; substantially increased time spent with others, causing minor
How much more time than usual for you does this represent? impairment, e.g., inappropriate renewing of old acquaintances
Did you make social contact with people whom you do not know or have not
seen in a long time? What about talking on the phone, or using the internet for 4 Marked increase in social interactions, associated with intrusive, unwanted
conversations? interactions, contacts strangers

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29. Racing thoughts-reported: Rapid flow of ideas, which may be observable 0 Not at all
in speech. There is continuity of thought, although it maybe difficult or 1 Slight; e.g., feels talkative
impossible to stay on track with the content. Rate on subjective report.
2 Mild; e.g., free, lively associations, not interfering with person’s staying on
Have you been bothered by having too many thoughts at once? track
Have your thoughts been speeded up?
3 Moderate; e.g., rapid flow of ideas, with difficulty returning to primary
Has this caused any difficulties in staying on track? theme of thoughts
How much of the time has this happened?
Is it moderate or severe over the past week? 4 Severe; e.g., constantly feels thoughts racing, has great difficulty collecting
thoughts and returning to main focus

30. Pressured speech: Pressure of talk, increased flow of speech, overly 0 Not at all
loquacious. Rate both observed and reported behavior. 1 Slight; e.g., tendency to talk excessively, not impairing
Have you experienced yourself talking too fast, saying too much in 2 Mild; e.g., rapid, verbose speech. Gives detailed answers
conversations?
Did others have to interrupt to get a word in? 3 Moderate; e.g., garrulous, difficult to interrupt
Has this interfered with your effectiveness in conversations? 4 Severe; e.g., speaking almost constantly. Words come tumbling out.
Cannot be interrupted most of time.

31. Increased sexuality: Stronger sexual interest than usual. May be reflected 0 Not at all
in an increase in sexual activities or fantasies. Judge in comparison with 1 Slight increase in sexual interest
subject’s usual sexual habits when well.
2 Mild increase in sexual interest, e.g., fantasies that at times preoccupy
How has your interest in sexual activities been the past week? patient
Have you thought about, or talked about sexual matters more
than usual? 3 Moderate; e.g., definite increase in sexual interest or activities, or intrusive
What has your level of sexual activity been? sexual fantasies
4 Severe; e.g., preoccupied with sexual fantasies. Marked increase in sexual
activities

32. Less need for sleep: Less need for sleep during the past week. A patient 0 No reduced need for sleep in past week
could be scored positive on this item as well as items 17 and 18 for 1 Slight; up to 1 hour less than usual
impaired sleep.
2 Mild; up to 2 hours less than usual
Have you needed less sleep than usual to feel rested?
3 Moderate; up to 3 hours less than usual
How many hours did you sleep? How many days in the last week did you have
a reduced need for sleep? How much sleep do you ordinarily need? 4 Severe; 4 or more hours less than usual

33. Grandiose: Increased self-esteem and appraisal of his/her worth, contacts, 0 Not at all
power or knowledge (up to grandiose delusions) as compared with 1 Slight; e.g., is more expansive, confident than most people in similar
usual level. Persecutory delusions should not be considered evidence of circumstances
grandiosity unless the subject feels the persecution is due to some special
attributes of his/hers (e.g., power, contacts.) 2 Mild; e.g., definitely inflated self-esteem or exaggerates talents somewhat
out of proportion to circumstances
Have you felt more self-confident than usual?
Have you felt that you are a particularly important person, or that you 3 Moderate; e.g., inflated self-esteem clearly out of proportion to
have special talents, abilities? circumstances
What about special plans? 4 Severe; e.g., grandiosity also may have delusional component

34. Elated: Elevated mood and/or optimistic attitude toward the future, out of 0 Not at all
proportion to the circumstances. 1 Slight; e.g., good spirits more cheerful than most people in similar
Have there been times when you felt very good or too cheerful or circumstances, but of only doubtful clinical significance
high—not just your normal self? 2 Mild; e.g., definitely elevated mood and optimistic outlook that is
Did you feel on top of the world or as if there was nothing you somewhat out of proportion to the circumstances
couldn’t do?
Have you felt that everything would work out just the way you wanted? 3 Moderate; e.g., mood and outlook are clearly out of proportion to
circumstances
4 Severe; e.g., quality of euphoric, exalted mood

35. Sharpened thinking: Has experienced unusually sharp and clear thinking, 0 Not at all
associated with creativity, problem solving capabilities. 1 Slight; e.g., brief periods of thinking more clearly or creatively
Have there been periods when your thinking seemed especially clear 2 Mild increase in clarity or creativity of thought
during the week?
Do you recall having had any unusually creative ideas or approaches 3 Moderate increase; e.g., believes that has important insight into personal
to problems? or external affairs but, with real evidence for this
How different was that from when you are feeling normal? 4 Marked; e.g., most of time thinking seems exceptionally clear, creative,
may be associated with some adverse consequence, e.g., acts on basis of
belief in plans, but without reasonable chance of success in action taken

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36. Elevated evening energy, interests: Increases in energy, activity, or 0 Not at all
interests in evening/night period. 1 Slight; e.g., frequently has more energy, interests in evening that delay
Has your energy, activity or interests been about the same throughout time of getting to bed by up to 1 hour
the day? 2 Mild; e.g., most evenings takes on activities that delay time getting to
Have you had any tendency to be particularly active or take on projects sleep by up to 2 hours, feels more energized most evenings/nights with
in the evening or at night? difficulty calming down. Has difficulty discontinuing activities at night.
Have you had more energy during the evening or nighttime?
3 Moderate; e.g., definite impairment from increased diurnal energy,
Have these kept you up past your usual hour of going to bed, interests in evenings. Stays up, active beyond midnight. Sleep delayed by
or beyond midnight? over 2 hours.
Has it ever been difficult to stop what you are doing, e.g., reading, TV,
project at night? 4 Severe; e.g., marked interference with time that sleep period starts, and
interference with ordinary daytime activities due to elevated energy,
activity, or interests in the evening/night

37. Impulsive: Makes decisions, starts actions without considering 0 Not at all
consequences. Impulsivity may be associated with intrusiveness, spending, 1 Slight; e.g., occasional impulsive action with little or no adverse
criticism of others, sexual behavior. consequences
Have you made any decisions without thinking the situation through? 2 Mild; e.g., frequent mildly impulsive actions with some adverse
Have you made any snap judgments? Have you talked when you should consequences, e.g., mild speeding, cutting in line
have kept quiet or taken on a project without thinking it through?
3 Moderate; e.g., frequent impulsive actions, with actual or realistic potential
Have you been able to control your responses when placed in a situation where for adverse consequences such as firing, legal charge, traffic ticket.
a decision or choice is needed? Have you been patient or impatient when you Impulsivity is evident during the interview
have had to stand in line, say at a check out counter? Have you cut in line?
Have you bought things that you did not need? 4 Severe; serious impairment from impulsivity; e.g., accident with medical
consequences, ticketed by the police

38. Distractible: Attention easily diverted by external stimuli. Rate principally 0 Not at all
on observed behavior. 1 Slight; e.g., attention occasionally distracted by irrelevant stimuli, such as
Do you notice that your attention shifts to other things taking place background noises
around you? 2 Mild; e.g., easily distracted, but returns to primary theme without
Have you been easily distracted by your surroundings? prompting
Have you found this causing you to have difficulty in staying on a subject in 3 Moderate; e.g., relatively frequent distraction, has difficulty getting back
conversation, or to concentrate? on track, even with prompting
4 Severe; e.g., continually distracted by incidental events and objects, which
makes interviewing difficult

39. Risky behavior: Involvement in activities with high potential for adverse 0 Not at all
consequences socially, legally, financially or sexually. 1 Slight; e.g., thoughts of promiscuous behavior, moderately aggressive
Have you done anything that was risky or got you in trouble? driving
Have spent more than you can afford? Have you told someone off 2 Mild; e.g., places self in situations with some risk for injury, attention by
unnecessarily, driven too fast, or done any other things that could have police, contracting communicable disease
gotten you into trouble? Have you used any drugs that could be harmful
to you? 3 Moderate; e.g., frequent risk taking, with at least one serious risk taking
action
How often has this occurred over the past week? Can you give an example?
4 Severe; e.g., argues with officials without provocation, runs red lights,
solicits sex

40. Affective lability: Reported and observed spontaneous sharp shifts of 0 Not at all
affective or mood states lasting from minutes to hours. Lability may or may 1 Slight; e.g., occasional periods of fluctuating mood, affects, generally
not be influenced by circumstances. Often described metaphorically: “I am within a day, of questionable clinical significance
on a roller coaster, I am like a yo yo.” Affects can be sad, giddy, angry, or over
confident. Do not rate on basis of what affective states are expressed. Rate 2 Mild; e.g., frequent mild, mood instability or lability which family, close
on proportion of time with lability, degree of inability to control affective associates see as dysfunctional
shifts. 3 Moderate; e.g., definite impairment in social, work role function from
How steady has your mood been? frequent mood instability
Do your emotions shift fairly suddenly at times? 4 Serious impairment from mood lability. Persists most of day, most days,
How much of the time are you this way? When this happens can you put a halt interferes with most social, work, role functions
to it? Does it interfere in your daily life?

41. Persecutory ideas: From slight distrustfulness through suspiciousness and 0 Not at all
delusions of persecution. Does not include feelings or beliefs which are 1 Slight feelings of distrustfulness which may be realistically based and are
completely justified by the situation. of doubtful clinical significance
Have people been making life hard or deliberately causing you trouble 2 Mild; suspiciousness definitely not warranted by the situation, but only
or trying to hurt you? occasional and of mild intensity, e.g., often feels taken advantage of
Have you had to be on guard with people?
3 Moderate; often suspicious or distrustful, but clearly ideas of reference that
Have you felt distrustful of others, or afraid that they would take advantage of are recognized as the imagination
you? Have you felt that you have been singled out, or targeted for their actions
against you? 4 Severe; pervasive suspiciousness, or persecutory feelings of delusional
intensity, e.g., plot may exist against him/her

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42. Delusions: Severity of delusions of any type—consider conviction in 0 Not at all

delusion preoccupation, and effect on actions. Ask questions appropriate 1 Slight; suspected or likely, but not impairing
to eliciting delusional ideation.
2 Mild; delusion definitely present, but at times subject questions it as a
Has your imagination been playing tricks on you in any way? false belief
Have you had any ideas that other people might not understand?
3 Moderate; delusion has a significant effect on thoughts, feelings, actions,
Did you think this was your imagination? e.g., asks family to forgive sins, preoccupied with belief that he or she has
Have you felt controlled by an outside power? special power.
What did you do about __________?
4 Severe; delusions have major impact on patient or others, e.g., has
delusions of control, calls emergency number about space invaders

43. Hallucinations: Severity of hallucinations of any type. Consider conviction 0 Not at all
in reality of hallucination, preoccupation, and effects on behaviors. Ask 1 Slight; occasional altered perception of doubtful clinical significance
questions appropriate to eliciting hallucinations.
2 Mild; definitely present, but is generally aware that it is imagination and is
Have you heard voices or other things that weren’t there or that other usually able to ignore it
people couldn’t hear?
Has there been anything unusual about the way things looked or 3 Moderate; generally believes in the reality of the hallucination, but it has
sounded or smelled? little influence on behavior
Do you think __________ was your imagination? 4 Severe; convinced the hallucination is real and it has significant effects on
What did you do about it? actions, e.g., locks doors to keep heard pursuers away

44. Impaired insight: Awareness, understanding of his/her emotional illness, 0 Not at all; insight is present, patient admits, understands illness and need
aberrant behavior, and corresponding need for psychiatric treatments. for treatment
Why are you coming for psychiatric treatment? 1 Slight impairment; patient feels he/she is ill, or needs treatment, but has
Do you feel that you currently have an emotional problem, little insight into history of illness or what characterizes the illness.
or mental illness? 2 Mild; admits behavior is changed, or need for treatment, but attributes it
Do you believe that you need psychiatric treatment? to a nonpsychiatric external factor (i.e., marital conflict, stress). Factors are
How would you explain your (behavior, symptoms, etc)? plausible and non-delusional.
3 Moderate impairment; admits behavior is changed, or need for treatment,
but gives implausible or delusional explanations
4 Severe; denies behavior change, illness, or need for treatment
Version 1.5 (4/1/08)
Developed by Charles L. Bowden, MD, Vivek Singh, MD, Peter M. Thompson, MD, Jodi Gonzalez, PhD, Thomas J. Prihoda, PhD, Martin M. Katz, PhD,
Rolando A. Medina, MD, MPH, Martha Dahl, RN, Tyler J. Burnett, MSSW, and Xiaoying Chang, MD
Supported in part by the Fund for Excellence in Psychiatric Research and the Center for Bipolar Illness Intervention in Hispanic Communities
(NIMH: 1-P20-MH68662-01A1)
© 2005 Charles L. Bowden, MD
All rights reserved. No part of this document may be reproduced or transmitted in any form, or by any means, electronic or mechanical, including photocopying, or
by any information storage or retrieval system, without permission in writing from Dr. Bowden, 7703 Floyd Curl Dr., Department of Psychiatry, University of Texas
Health Science Center at San Antonio, San Antonio, TX 78229, bowdenc@uthscsa.edu. Researchers and clinicians working in nonprofit or publicly owned settings
(including universities, nonprofit hospitals, and government institutions) may make single copies of a BISS instrument for their own use.

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