Scale for the Assessment of Negative Symptoms, SANS Test - the question form
Questions: 25 · 5 minutes
1. Unchanging facial expression. The patient’s face appears fixed or “wooden” and does not change during conversation on emotional topics.
0 – Absent: facial expression is completely lively
1 – Questionable reduction in facial expressiveness and animation
2 – Mild: facial expressiveness is slightly reduced, or the face becomes fixed intermittently
3 – Moderate: facial expressiveness is clearly reduced
4 – Marked reduction in facial expressiveness, but facial reactions may occur at times
5 – Severe: the face is a fixed (“wooden”) mask that does not change during the interview
2. Decreased spontaneous movements. The patient sits motionless during the interview or makes a limited number of spontaneous movements.
0 – Absent
1 – Questionable pathology
2 – Mild – some reduction in spontaneous movements
3 – Moderate – clear reduction in spontaneous movements; the patient moves no more than 3–4 times during the interview
4 – Marked decrease in motor activity, no more than 1–2 movements during the interview
5 – Severe – the patient sits motionless, in a fixed posture, throughout the entire interview
3. Paucity of expressive gestures. The patient does not use body movements to make thoughts more expressive.
0 – Absent – gesturing is within normal limits or excessive
1 – Questionable pathology
2 – Mild – gesturing is only slightly reduced
3 – Moderate – clear reduction in expressive gesturing
4 – Marked reduction in expressive gesturing
5 – Severe – the patient never uses body movements to emphasize the expressiveness of thoughts and emotions
4. Poor eye contact. The patient avoids looking the interviewer and others in the eye and does not use gaze to emphasize the expression of feelings.
0 – Absent; gaze expressiveness and eye contact are within normal limits
1 – Questionable reduction in eye contact
2 – Mild – some reduction in eye contact and gaze expressiveness
3 – Moderate – definite reduction in eye contact and gaze expressiveness
4 – Marked reduction in eye contact; the patient rarely makes eye contact with the interviewer
5 – Severe – the patient almost never looks at the interviewer
5. Emotional (affective) unresponsiveness. The patient does not smile or laugh during the interview, even in response to jokes.
0 – absent
1 – questionable pathology
2 – mild; slight but definite reduction in responsiveness
3 – moderate; clear reduction in emotional reactions
4 – marked absence of emotional responding most of the time
5 – severe; complete absence of emotional reactions even with provocation
6. Inappropriate affect. The patient’s affect (emotional responses) is inappropriate or does not match the stimulus that elicited it.
0 – absent
1 – questionable pathology
2 – mild – at least one instance of inappropriate affect (smile, etc.)
3 – moderate – several instances of inappropriate affect during the interview
4 – marked – frequent instances of inappropriate affect
5 – severe – inappropriate affective responses occur during most of the interview
7. Lack of vocal inflections (monotone voice). The patient speaks in a monotone, without inflection, with little or no change in pitch or loudness.
0 – Absent
1 – Questionable reduction
2 – Mild reduction in vocal inflections
3 – Moderate – clear reduction in vocal modulation and inflection
4 – Marked reduction in vocal inflections
5 – Severe – speech is completely monotone
8. Global rating of affective flattening. The rating should be based on the overall severity of the symptom, especially reduced emotional responsiveness, speech intonation, facial expressiveness, and eye contact.
0 – Absent
1 – Questionable pathology
2 – Mild affective flattening
3 – Moderate affective flattening
4 – Marked affective flattening
5 – Severe affective flattening
9. Poverty of speech. Quantitative reduction in spontaneous speech output, reflected in limited verbal expression. Answers are brief, concrete, and formal, with no elaboration, or may be absent.
0 – none – responses are detailed and appropriate
1 – questionable pathology – the patient’s speech provides additional information
2 – mild – responses are on topic but do not provide complete information
3 – moderate – some answers do not provide sufficient information; many answers are monosyllabic and very brief (e.g., “Yes,” “No,” “Maybe,” “I don’t know,” “Last week”)
4 – marked poverty of speech – responses are rarely given as complete sentences; mostly single words
5 – severe – the patient says almost nothing and at times does not answer questions at all
10. Poverty of content of speech: The patient’s verbal responses convey little meaningful information; may include unclear phrasing, overly abstract or overly concrete statements, repetitions, or stereotyped expressions, despite adequate amount of speech.
0 – Absent
1 – Questionable pathology
2 – Mild: some responses are difficult to understand or could be substantially more concise
3 – Moderate: responses are often difficult to understand or could be shortened by at least one quarter
4 – Marked poverty of content of speech: at least half of responses are difficult to understand
5 – Severe: almost all speech is incomprehensible or could be greatly shortened
11. Speech blocking (thought blocking): interruption of the continuous flow of speech before an idea is completed.
0 – Absent
1 – Questionable pathology
2 – Mild – one episode of blocking in 15 minutes
3 – Moderate – two episodes in 15 minutes
4 – Marked – three episodes of speech blocking in 15 minutes
5 – Severe – more than three episodes in 15 minutes
12. Response latency. The patient answers questions with a delay and appears detached.
0 – Absent
1 – Questionable pathology
2 – Mild – some responses are preceded by brief pauses
3 – Moderate – responds with clear delay (pauses of several seconds)
4 – Marked delay in responding to questions
5 – Severe – long pauses before every response
13. Global rating of alogia. Rate primarily the severity of the core features of alogia, that is, poverty of speech and poverty of content of speech.
0 – Absent
1 – Questionable pathology
2 – Mild; slight but definite poverty of speech
3 – Moderate; definite poverty of thought and speech production
4 – Marked poverty of speech and thought most of the time
5 – Severe; thought and speech are impoverished virtually all the time
14. Unkempt appearance and poor personal hygiene. The patient pays little attention to appearance; clothing may be old, dirty, and in disrepair.
0 – Absent
1 – Questionable pathology
2 – Mild: minimal but noticeable inattention to appearance and personal hygiene, including uncombed hair, unclean or worn clothing, etc.
3 – Moderate: unkempt appearance, including dirty hair and dirty clothing
4 – Marked: pronounced unkemptness and neglect of appearance; hygiene practices are minimal
5 – Severe: extreme neglect of clothing, appearance, and bodily hygiene
15. Lack of persistence at work or in school. Difficulty finding and keeping a job, finishing school, managing household responsibilities; in hospitalized patients, difficulty participating in everyday and social activities.
0 – Absent
1 – Questionable pathology
2 – Mild – lack of persistence at work and in school is slight but noticeable
3 – Moderate – clearly noticeable lack of persistence at work and in school
4 – Marked – major difficulties in school and in finding and keeping even simple work
5 – Severe – persistent difficulties; unable to work
16. Physical anergia. The patient appears physically inert and may sit for long periods doing nothing, mindlessly watching television, or staying in bed.
0 – Absent
1 – Questionable pathology
2 – Mild – anergia is slight but noticeable
3 – Moderate – stays in bed or sits in a chair at least one-quarter of the time while awake
4 – Marked anergia – stays in bed at least half of the time while awake
5 – Severe – lies down or sits almost the entire day
17. Global rating of avolition–apathy. A high rating may be given when one or two signs are markedly severe.
0 – absent
1 – questionable pathology
2 – mild but definite
3 – moderate
4 – marked pathology
5 – severe
18. Decreased recreational interests and activity. Rate both the quality and the quantity of hobbies/interests. The number of interests may be limited, or interest in any creative activity may be lost.
0 – Absent – interests fully intact
1 – Questionable pathology
2 – Mild – slight but noticeable decrease in interests; able to experience pleasure only from passive leisure activities (e.g., watching television), and only episodically
3 – Moderate – often unable to experience pleasure in recreational activities
4 – Marked – marked loss of interests and inability to experience pleasure in any activity
5 – Severe – complete absence of interests and ability to experience pleasure
19. Sexual interest and activity
0 – Absent: normal sexual interest and activity
1 – Questionable pathology
2 – Mild: slight but noticeable reduction in sexual activity
3 – Moderate: clear reduction in sexual interest and satisfaction from sex
4 – Marked: marked reduction in sexual activity; no interest in sexual activity and no enjoyment of it
5 – Severe: complete absence of sexual activity and inability to experience sexual pleasure
20. Capacity for intimacy and closeness (e.g., warmth toward family members; avoidance of close relationships with relatives or opposite-sex partners).
0 – Not present
1 – Questionable pathology
2 – Mild – slight but noticeable reduction in capacity for intimate feelings
3 – Moderate – clear reduction in the ability to form warm, close relationships
4 – Marked reduction in the ability to form warm, close relationships, including with family members
5 – Severe – complete inability to show close feelings; avoids contact with family members and is hostile toward them
21. Relationships with friends and coworkers (may have no friends or few friends, especially close friends, and may prefer to spend time alone).
0 – Absent – ability to form friendships is intact
1 – Questionable pathology
2 – Mild – has some difficulty making friends
3 – Moderate – has significant difficulty establishing and maintaining friendships
4 – Marked restriction of relationships with friends and coworkers; prefers to spend time alone
5 – Severe – has no friends and is not interested in making friends; spends most of the time alone
22. Global rating of anhedonia–asociality.
0 – Absent
1 – Questionable pathology
2 – Mild – slight but noticeable signs of anhedonia and social withdrawal
3 – Moderate – definite signs of anhedonia and social withdrawal
4 – Marked anhedonia and social withdrawal
5 – Severe – virtually complete anhedonia and social isolation
23. Inattention during social activities. The patient appears distractible, uninterested, and not engaged in various social activities.
0 – Absent
1 – Questionable pathology
2 – Mild; slight but noticeable difficulty
3 – Moderate; clear difficulty concentrating and sustaining attention; sometimes misses what is happening around them
4 – Marked inattention; often does not notice what is happening around them; difficulty reading and understanding text
5 – Severe; unable to sustain conversation and participate in any social activity (virtually unable to read, follow a movie plot, etc.)
24. Attention impairment on formal testing: impairment in carrying out test tasks.
0 – Absent – completes tests.
1 – Questionable – completes tests without errors, but with hesitation and self-corrections.
2 – Mild – makes 1 error.
3 – Moderate – makes 2 errors.
4 – Marked – makes 3 errors.
5 – Severe – makes more than 3 errors.
25. Global rating of attentional impairment. The rating should be based on the overall severity of attentional impairment, taking into account both clinical-social functioning and test performance.
0 - Absent
1 - Questionable pathology
2 - Mild - attentional impairment is slight but noticeable
3 - Moderate - definite attentional impairment
4 - Marked attentional impairment
5 - Severe - unable to maintain attention in conversation; interview not possible