Journal of Affective Disorders 122 (2010) 179–183

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Journal of Affective Disorders

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Brief report

The Observer-Rated Scale for Mania (ORSM): development, psychometricproperties and utility

Stephanie Krüger a,⁎, Lena Quilty b, Michael Bagby c, Torsten Lippold d,Felix Bermpohl e, Peter Bräunig f

a Klinik und Poliklinik für Psychiatrie und Psychotherapie, Charité Campus Mitte, Universitätsmedizin Berlin, Germanyb C. Psych. Department of Psychiatry, University of Toronto Clinical Research Department, Centre for Addiction and Mental Health, Canadac Center for Addiction and Mental Health, Mood Disorders Division, University of Toronto, Canadad Klinik für Psychiatrie, Psychotherapie und Psychosomatik am Humboldt Klinikum Vivantes, Berlin, Germanye Klinik und Poliklinik für Psychiatrie und Psychotherapie, Charité Campus Mitte, Berlin University Medicine, Germanyf Klinik für Psychiatrie, Psychotherapie und Psychosomatik am Humboldt Klinikum Vivantes, Berlin, Germany

a r t i c l e i n f o

⁎ Corresponding author. Klinik für Psychiatrie und PCampus Mitte, Universitätsmedizin Berlin, CharitépGermany. Tel.: +30 450 517 216; fax: +30 450 5179

E-mail address: stephanie.krueger@charite.de (S. K

0165-0327/$ – see front matter © 2009 Elsevier B.V.doi:10.1016/j.jad.2009.07.022

a b s t r a c t

Article history:Received 11 May 2009Received in revised form 22 July 2009Accepted 22 July 2009Available online 28 August 2009

Background: The diagnosis of mania largely depends on the quality of information thephysician is provided with. Often, the patient cannot give an accurate account of the symptomdevelopment and thus information from relatives and friends is required. No systematic ratinginstrument is available, however, to facilitate this.

Objective: In this study, the psychometric properties of the 49-item Observer-Rated Scale forMania (ORSM) are reported.

Methods: The scale was used in 113 inpatients and the following psychometric aspects wereassessed: reliability, test–retest reliability, construct validity (factor analysis, discriminantanalysis, comparison of means), extreme-group validity, prognostic validity, sensitivity,specificity, positive and negative predictive values.

Results: The ORSM proved highly valid and reliable. Factor analysis revealed three factorswhich were labelled euphoric mania, instable mania and psychotic mania.

Conclusion: The ORSM is a useful instrument to help non-professionalswho are in regular contactwith the patient diagnosed amanic/mixed episode. It thus complements existing rating scales formania, which are either designed for professionals or are self-rating instruments.

© 2009 Elsevier B.V. All rights reserved.

Keywords:Observer-rated scale for maniaDiagnosisRelativesFamilies

1. Introduction

The diagnosis ofmania is a complex task. Manic statesmaydevelop over days or weeks (Winokur, 1976; Molnar et al.,1988; Keitner et al., 1966; Jackson et al., 2003) and often are sosevere on admission that making a proper diagnosis is noteasy. In addition, manymanic patients are uncooperative, lackinsight and require rapid treatment. Studies suggest that the

sychotherapie, Charitélatz 1, 10117 Berlin,44.rüger).

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risk of misdiagnosing a manic patient who is dysphoric,psychotic, uncooperative or aggressive as schizophrenic ishigh (Demily et al., 2009; Altamura and Goikolea, 2008;Pihlajamaa et al., 2008). This has important consequences foracute and long-term treatment.

The clinician's diagnostic window is small and oftenencompasses only a cross-sectional impression. Systematicrating scales (Shugar et al., 1992; Bräunig et al., 1996; Altmanet al., 1997; Akiskal et al., 2001; Beigel and Murphy, 1971;Blackburn et al., 1977; Young et al., 1978; Bech et al., 1979)have attempted to reduce the bias associated with thediagnosis of mania. However, current observer-rated scalesfor mania assess the current status of the patient only andrequire clinical resources and time.

180 S. Krüger et al. / Journal of Affective Disorders 122 (2010) 179–183

Relatives and other persons close to the patient are animportant source of information when the patient cannotprovide it him- or herself. In schizophrenia, there is evidencethat relatives are more sensitive to early signs and symptomsof the disease than patients themselves (Hambrecht andHäfner, 1997b; Tierney et al., 2003). Furthermore, systematicrating scales for relatives of schizophrenic patients correlatewell with instruments used by professionals (Hambrecht andHäfner, 1997a,b; Tierney et al., 2003). Similar findings comefromstudies onAlzheimer's disease (Ippen et al., 1999), ADHD(Ickowicz et al., 2006) and juvenile bipolar disorder (Graciouset al., 2002), where rating scales for relatives have successfullybeen integrated into clinical practice.

Based on these positive findings, we developed a maniarating scale that can be used by individuals who are in closecontact with the patient in order to assess mania and todetermine its severity. The psychometric properties of thisrating scale are reported here.

2. Methods

2.1. Development of the Observer-Rated Scale for Mania (ORSM)

The ORSM is an instrument designed to obtain significantinformation on the signs and symptoms of mania in the weekprior to hospital admission. It is designed for those in regularcontact with the bipolar patient to facilitate systematicobservation of mood and behavioural changes.

The scale was developed by the senior and the firstauthor and originally consisted of 57-items. To ensurecontent validity, items were selected to reflect each of themajor symptoms and behaviours of mania. They were basedon literature review, clinical experience and internal consen-sus in a consultative iterative process. The original scale wasrevised to a 49-item scale based on a pilot trial with 15families, internal methodological and statistical review.Duplicate wordings and operational variants of many itemswere discarded. Families of bipolar patients ascertained thatthe scale appeared valid to the subjects for whom it wasdesigned. This process established that the final items of thescale appeared relevant and plausible, reducing the likelihoodof poor cooperation, which might result if future respondentsviewed the test content as trivial or irrelevant.

Theprocessof scale development andvalidationwasguidedby an a priori statistical plan, developed by a statistician and bythe senior author of this paper, who has previously developedand validated a self-rating scale formania (MSS) (Bräunig et al.,1996) and a rating scale for catatonia (BCRS) (Bräunig et al.,2000; Krüger et al., 2003).

The 49-item version of the ORSM covers the followingdomains: euphoric/dysphoric mood, disinhibition, affectivelability, motor symptoms, cognitive function, psychoticsymptoms, disturbance of biorhythm, and insight. All itemsare close-ended, to be answered true or false. Many arewritten in the comparative (e.g. he/she had more energy, he/she was more agitated). It takes about 10 min to fill out thescale.

For this publication, the items of the ORSMwere translatedinto English (original in German) by one of the authors (S.K.)and retranslated into German by a native speaker to ascertainthat the primary translation was correct.

2.2. Subjects

The study took place at the Klinik für Psychiatrie, Psy-chotherapie und Psychosomatik am Klinikum Chemnitz,Germany, a teaching hospital of the University of Dresdenwith which the second and the senior authors were affiliatedat the time of study conduction. Statistical analysis wasperformed by the Centre for Clinical Studies of the Universityof Dresden. The studywas approved by the local ethics reviewboard. All subjects gave informed consent to participate in thestudy.

One-hundred and thirteen patients were included in thestudy. All patients were diagnosed according to DSM-IVcriteria (APA, 1994). Patients with substance abuse disorders,organic psychoses, and personality disorders were excluded.Patients were required to have one significant person whowas in regular contact with the patient including the weeksprior to admission.

2.3. Assessment of psychometric properties

In order to ensure construct validity, the ORSM was com-pared to other gold standards of rating scale diagnosis: theYoung Mania Rating Scale (YMRS) (Young et al., 1978), theSelf-Report Manic Inventory (SRMI) (Shugar et al., 1992),the Brief Psychiatric Rating Scale (BPRS) (Overall andGorham,1962), the Hamilton Depression Scale (HAM-D) (Hamilton,1960), theBeckDepression Inventory (BDI) (Beck et al., 1961).The self rating scales were used in order to assess the overlapbetween patients' and third parties' observations. All scaleswere administered within two days of admission (T1) andagain 3 weeks (T2) after hospitalisation to assess test–retestreliability.

The ORSM was subjected to the following statisticalanalyses: reliability, test–retest reliability, construct validity(factor analysis, discriminant analysis, comparison of means),extreme-group validity, prognostic validity, sensitivity, spec-ificity, positive and negative predictive values.

3. Results

3.1. Diagnostic sample

Of the 113 patients, 31 (28%) fulfilled the DSM-IV criteriafor a manic episode (12 (11%) with and 19 (17%) withoutpsychotic features). 24 (21%) patients were diagnosed withschizophrenia, 41 (36%) with depression and 17 (15%) withanxiety disorders including obsessive compulsive disorders.Mean agewas 37.4 years (SD 7.3 years), there was a slight butnot statistically significant preponderance of women in thesample (F: 61, M: 53).

The manic patients were characterized as follows: meanduration of illness 14.2 (SD 4.6) years, mean number ofdepressive/manic episodes 12 (SD 4.3)/6 (SD 3.8). Theaverage YMRS/SRMI scores were 36 and 24 respectively.

Table 1 gives an overview of the type of third partyinformation. The majority (N=81, 71.7%) of patients haddaily contact with their relative; in the remaining patients,there was intensive contact (3–4 times a week). There wereno differences between the diagnostic groups with respect tothese parameters.

Table 1Type and frequency of third party information.

Type of contact Frequency of type of contact N (%)

Spouse 41 (36.3)Common law 34 (29.7)Parent 24 (21.3)Child 6 (5.4)Sibling 3 (2.7)Other relatives 5 (4.4)

181S. Krüger et al. / Journal of Affective Disorders 122 (2010) 179–183

3.2. Psychometric properties of the ORSM

3.2.1. Reliability, test–retest reliabilityTest–retest reliability of the ORSMwas high. The intraclass

correlation coefficients were .87 for each individual item andPearson's correlation coefficients were .89 at T1 and .76 at T2,pb .01. Cronbach's alpha was .89 indicating that the ORSM ishighly homogenous and that each item contributes indepen-dently to the total score.

3.3. Content validity

3.3.1. Criterion-validityIn order to assess criterion validity, the ORSM was cor-

related at T1 and T2 with DSM-IV diagnosis, the YMRS, theMSS, the HAM-D, the BPRS and the BDI. DSM-IV diagnosis wasdetermined as the gold standard and the external criterion. Asexpected, there were significant negative correlations withthe HAM-D and the BDI, both at T1 and T2.

Correlations with DSM-IV were high with a Pearson'scorrelation coefficient of .74 for T1 (pb .01) and .70 for T2(pb .01). Similarly, Pearson's correlation coefficient for theYMRS for T1 was .75 (pb .01) and .76 (pb .01) for T2 and forthe MSS .65 (p=.03) for T1 and .62 for T2 (pb .03). Cor-relations with the BPRS were not significant.

3.4. Construct validity

3.4.1. Comparisons of meansMean scores were calculated for all rating scales at T1 and

T2 for patients diagnosed with mania and other diagnosticgroups. As expected, rating scale scores for patients withmania showed significant differences compared with non-manic patients on all rating scales with the exception of theBPRS mean scores at times 1 and 2. For the ORSM, the meanscore for manic patients at T1 was 34. 4 (SD 8) and for non-manic patients 2.1 (SD 3) (T: 10.8, df: 39.6, pb .01). For T2 itwas 30.1 (SD 4) for manic and 5.6 (SD 6.3) for non-manicpatients (T: 8.6, df: 36.3, pb .01).

3.5. Factor analysis

The Kaiser–Meyer–Olkim of sampling adequacy was .719suggesting thematrix was suitable for factor analysis (Varimaxrotation). Eigenvalues greater than 1 and scree test criteriaindicated the relative suitability for either a three or four factorsolution. Parallel analysis indicated that no more than fourfactors could be reliably extracted. To this end, both three andfour factors were rotated to a varimax solution. The four factormodel accounted for 75.1% of the variance, however, the fourth

factor accounted for less than 5% of the variance (4.6) and wascomposed of two items (decreased need for sleep and insightinto illness) only. Based on these results, we considered thisfourth factor ‘trivial’ and a three-factor solutionwas accepted asthemost suitable. The three-factor solution accounted for 70.5%of the variance. Table 2 displays the three factors and theirrespective significantly loading items.We labelled these factors(I) euphoricmania (II) instablemania and (III) psychoticmania.

3.6. Sensitivity, specificity, positive and negative predictive values

Highest values for both sensitivity and specificity at T1were 0.96. The Youden-index (ranges between 0 and 1 indiagnostic tests, with 1 indicating the highest sensitivity andspecificity) was calculated with 0.78, the respective cut-offwas 16. At this cut-off value, sensitivity was 83.8% andspecificity was 94%. Based on this, we calculated positive andnegative predictive values. At a cut-off of 16, 94% of manicpatients were correctly classified by the ORSM (positivepredictive value) and 89% of non-manic patients werecorrectly classified (negative predictive value).

Similar resultswere achieved at T2: the cut-off here was 15.At this value, sensitivity is 76% and specificity is 93%. Positiveand negative predictive values are 75% and 86% respectively.

4. Discussion

The ORSM is the first instrument designed to detectsymptoms of mania by lay observers. The ORSM includesitems which allow for an assessment of patients with a widerange of severity and symptoms.

Reliability analyses generated strong findings suggestingthat the diagnosis of mania can bemade with a high degree ofaccuracy by non-professionals.

The ORSM proves to have high validity. Robust correlationcoefficients with clinician's diagnosis of mania and severity ofmanic symptoms based on DSM-IV and other mania ratingscales demonstrate that manic symptoms are assessedadequately. As expected, correlations with the HAM-D andthe BDI are weak, confirming that items of the ORSM are notconfounded by symptomsother than those of amanic episode.

Factor analysis provides evidence for the construct validityof the scale and complements clinical knowledge of thosesymptoms which underlie mania. The ORSM consists of 3factors: (Winokur, 1976) euphoric mania, (Molnar et al., 1988)instable mania and (Keitner et al., 1966) psychotic mania. Noother rating scale is designed to cover more than 2 dimensions,namely euphoric and dysphoric. The majority of ORSM itemsloaded on factor I and can clearly be attributed to euphoricmania. Items of irritability and dysphoria had higher loadingson factor II, but some on factor III as well, suggesting that thesesymptoms also occur in psychotic but not euphoric mania. Thesame applied to those items loading highly on factor III; theseloaded somewhat on factor II also. These three factorsmay helpin establishing individual treatment strategies.

Strengths of our study include the thorough scale con-struction, the representative study sample, and the rigorouspsychometric testing. Limitations include that the scale wasonly tested in a German speaking population. It is planned tofurther translate and validate the scale in non-German speakingsamples, as well as samples diverse in ethnicity and in other

Table 2Factor analysis of the Family-Rated-Mania Scale (FAMS).

Item (abbreviated) Factor I (euhphoric mania) Factor II (instable mania) Factor III (Psychotic mania)

Laughed more .851 .334 .011Was extremely euphoric .851 .145 .111Spent more time on the phone .851 .343 .194Enjoyed life more/did more pleasurable things .850 .211 .077Made all kinds of future plans .791 .210 .065Physically fitter/more vital .791 .056 −.013Expressed affection more freely .791 .124 −.134More interested in sex .790 .257 .322More sociable .744 .322 .214Enthusiastic about things that normally wouldn't be interested in .743 .421 .365Felt admired/adored by others .740 .064 .032Was more generous .740 .054 .016Gave away own possessions .711 .066 .029More talkative/could not stop talking .711 .121 .422Thoughts were racing through his/her mind .701 .344 .518Changed clothes several times/day, dressed flashily .701 .288 .021More lively gestures .701 .218 −.021Spent more money but still kept lid on it .699 .043 .010Spent more time on the phone .698 .188 .213Wrote down everything .633 .270 .011Easily bored .604 .437 .388Emotionally wound up/wired .073 .801 .388Easily disconcerted .102 .801 .211Emotions like on roller coaster — mood swings within hours .039 .795 .213Felt superior to others .446 .795 .199More self-righteous .265 .795 .365More sympathy for others .313 .795 .020People got in his/her nerves more easily .038 .714 .356Meddled with other peoples' business .049 .713 .322Got into arguments easier .048 .713 .319Uncontrolled outbursts of anger −.120 .713 .276Increased distractibility .099 .700 .175Started things without finishing them .288 .700 .187Wanted to do many things at same time .347 .700 .259Lost control over spending money .466 .698 .311Risky behaviors .434 .698 .394Felt threatened by others −.120 .346 .855Had suicidal thoughts/performed s. attempt −.179 .498 .855Was confused −.079 .232 .853Related things to self −077 .355 .843Was more suspicious −.056 .254 .755Thought someone was after him/her −.055 .165 .755Heard voices that were not real −.033 .065 .743Was sent by God/some force to save world .113 .288 .754Saw things that were not there −.034 −.143 .745Believed he/she had special powers .489 .488 .741He/she was more religious (praying, talking about God…) .117 .488 .389He/she needed less sleep .678 .597 .586He/she knew he/she was getting ill .311 .346 .213

Bold values are N.5.

182 S. Krüger et al. / Journal of Affective Disorders 122 (2010) 179–183

demographic and clinical characteristics. The sample size forfactor analysis was relatively small for a 49-item scale. It isplanned to replicate factor analyses in a larger sample. Ananonymous reviewer suggested that the factors of the ORSMmay reflect illness severity; the clinical utility of the ORSMfactors and this alternative interpretation might also beaddressed in future investigations.

5. Conclusion

The ORSM is the first mania rating scale developed toobtain information by lay observers. It was designed tofacilitate communication between physicians and families insituations where an accurate account of signs of mania is

required. This study provides supportive evidence of thereliability and validity of this instrument.

Role of funding sourceThere was no funding source involved for this study.

Conflict of interestNone of the authors have any conflicts of interest.

Acknowledgement

The authors thank the Center for Clinical Studies for per-forming the statistical analyses and for their advice regardingthe interpretation of the results.

183S. Krüger et al. / Journal of Affective Disorders 122 (2010) 179–183

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