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

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.

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

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

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.