HoNOS Training

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HoNOS Training

• Based on Allen Morris-Yates, Hugh Barber,
  Meredith Harris, and Siggi Zapart (2001)
  Collection of Standardised Measures under the
  SPGPPS National Model Hospital Staff Trainers
  Manual. Version 1.1, March 2002. Canberra,
  Strategic Planning Group for Private Psychiatric
  Services.

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HoNOS Training

• General rating guidelines
• Rate items in order from 1 to 12.
• Do not include information already rated in an
  earlier item.
• Rate the most severe problem that occurred in
  the period rated.
• The rating period is generally the preceding
  two weeks for inpatients at admission, for
  hospital outpatients, and for all clients of
  community-based services. The exception is at
  discharge from acute inpatient care, in which
  case the rating period should generally be the
  preceding 72 hours.

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HoNOS Training

• Each item is rated on a 5-point scale of
  severity (0 to 4) as follows
• 0 No problem
• 1 Minor problem requiring no formal action
• 2 Mild problem. Should be recorded in a care plan
  or other case record
• 3 Problem of moderate severity
• 4 Severe to very severe problem
• 7 Not known / Unable to rate
• As far as possible, the use of rating point 7
  should be avoided, because missing data make
  scores less comparable over time or between
  settings.
• Specific help for rating each point on each
  item is provided in the Glossary.

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HoNOS

• Alex is a forty-six year old father of 3 with
  principal diagnosis of Major Depression.
• 1. Alexs wife reports that over the last few
  weeks, Alex has been snapping at the children. He
  has also become very irritable and argumentative
  with her whenever she has not agreed with what he
  has said or wanted to do.

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1. Overactive, aggressive, disruptive or agitated
behaviour

• Include such behaviour due to any cause, eg.
  drugs, alcohol, dementia, psychosis, depression,
  etc. Do not include bizarre behaviour, rated at
  Item 6.
• 0 No problems of this kind during the period
  rated.
• 1 Irritability, quarrels, restlessness etc. not
  requiring action.
• 2 Includes aggressive gestures, pushing or
  pestering others threats or verbal aggression
  lesser damage to property (e.g. broken cup or
  window) marked overactivity or agitation.
• 3 Physically aggressive to others or animals
  (short of rating 4) threatening manner more
  serious overactivity or destruction of property.
• 4 At least one serious physical attack on others
  or on animals destruction of property (e.g.
  firesetting) serious intimidation or obscene
  behaviour.

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HoNOS

• 2. Alex took an overdose of sleeping tablets
  three days ago and was taken to the hospital
  emergency department. In an interview with the
  hospital psychiatrist Alex admitted that he has
  recently felt his family would be much better off
  without him and that he should do them a favour
  by ending it all.

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2. Nonaccidental selfinjury

• Do not include accidental selfinjury (due eg. To
  dementia or severe learning disability) the
  cognitive problem is rated at Item 4 and the
  injury at Item 5. Do not include illness or
  injury as a direct consequence of drug or alcohol
  use rated at Item 3, (eg. cirrhosis of the liver
  or injury resulting from drunk driving are rated
  at Item 5).
• 0 No problem of this kind during the period
  rated.
• 1 Fleeting thoughts about ending it all, but
  little risk during the period rated no
  selfharm.
• 2 Mild risk during period includes non
  hazardous selfharm eg. wristscratching.
• 3 Moderate to serious risk of deliberate
  selfharm during the period rated includes
  preparatory acts eg. collecting tablets.
• 4 Serious suicidal attempt or serious deliberate
  selfinjury during the period rated.

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HoNOS

• 3. Alex only drinks socially and occasionally.

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3. Problem drinking or drugtaking

• Do not include aggressive or destructive
  behaviour due to alcohol or drug use, rated at
  Item 1. Do not include physical illness or
  disability due to alcohol or drug use, rated at
  Item 5.
• 0 No problem of this kind during the period
  rated.
• 1 Some overindulgence, but within social norm.
• 2 Loss of control of drinking or drugtaking but
  not seriously addicted.
• 3 Marked craving or dependence on alcohol or
  drugs with frequent loss of control, risk taking
  under the influence, etc.
• 4 Incapacitated by alcohol or drug problems.

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HoNOS

• 4. Frequently forgets where he has put things or
  whether he has done something or not. Last week
  he went to the shop but came home as soon as he
  got there because he had forgotten what he wanted.

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4. Cognitive problems

• Include problems of memory, orientation and
  understanding associated with any disorder
  learning disability, dementia, schizophrenia,
  etc. Do not include temporary problems (eg.
  hangovers) resulting from drug or alcohol use,
  rated at Item 3.
• 0 No problem of this kind during the period
  rated.
• 1 Minor problems with memory or understanding eg.
  forgets names occasionally.
• 2 Mild but definite problems, eg. has lost way in
  a familiar place or failed to recognise a
  familiar person sometimes mixed up about simple
  decisions.
• 3 Marked disorientation in time, place or person,
  bewildered by everyday events speech is
  sometimes incoherent, mental slowing.
• 4 Severe disorientation, eg. unable to recognize
  relatives, at risk of accidents, speech
  incomprehensible, clouding or stupor.

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HoNOS

• 5. Has complained of bad headaches most days
  often needs to take a strong analgesic and lie
  down. He has missed several days of work during
  the last fortnight due to headaches. He is also
  coughing a lot and states his throat is dry and
  raspy.

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5. Physical illness or disability problems

• Include illness or disability from any cause that
  limits or prevents movement, or impairs sight or
  hearing, or otherwise interferes with personal
  functioning. Include sideeffects from
  medication effects of drug/alcohol use physical
  disabilities resulting from accidents or
  selfharm associated with cognitive problems,
  drunk driving etc. Do not include mental or
  behavioural problems rated at Item 4.
• 0 No physical health problem during the period
  rated.
• 1 Minor health problem during the period (e.g.
  cold, nonserious fall, etc.).
• 2 Physical health problem imposes mild
  restriction on mobility and activity.
• 3 Moderate degree of restriction on activity due
  to physical health problem.
• 4 Severe or complete incapacity due to physical
  health problem.

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HoNOS

• 6. No hallucinations or delusions.

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6. Problems associated with hallucinations and
delusions

• Include hallucinations and delusions irrespective
  of diagnosis. Include odd and bizarre behaviour
  associated with hallucinations or delusions. Do
  not include aggressive, destructive or overactive
  behaviours attributed to hallucinations or
  delusions, rated at Item 1.
• 0 No evidence of hallucinations or delusions
  during the period rated.
• 1 Somewhat odd or eccentric beliefs not in
  keeping with cultural norms.
• 2 Delusions or hallucinations (eg. voices,
  visions) are present, but there is little
  distress to patient or manifestation in bizarre
  behaviour, that is, clinically present but mild.
• 3 Marked preoccupation with delusions or
  hallucinations, causing much distress and/or
  manifested in obviously bizarre behaviour, that
  is, moderately severe clinical problem.
• 4 Mental state and behaviour is seriously and
  adversely affected by delusions or
  hallucinations, with severe impact on patient.

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HoNOS

• 7. Is feeling down all the time and is constantly
  on the verge of tears he almost burst into
  tears during a meeting at work last week. Since
  then he has been on sick leave. He says he has
  been having trouble sleeping. He lies awake all
  night thinking of what a useless husband and
  father he is he should have a better job and be
  bringing home more money (he actually has a very
  good, well paid job working as a Finance Manager
  for a local bank). His work has deteriorated
  because he is tired and cant concentrate. He
  also feels guilty that he lived when his brother
  died. He feels that he should have gotten cancer
  too. His wife reports that he has stopped doing
  the things he usually loves like listening to
  music, reading and gardening and seldom spends
  time playing with the children. She is also
  concerned at the amount of weight he has lost.

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7. Problems with depressed mood

• Do not include overactivity or agitation, rated
  at Item 1. Do not include suicidal ideation or
  attempts, rated at Item 2. Do not include
  delusions or hallucinations, rated at Item 6.
• 0 No problems associated with depressed mood
  during the period rated.
• 1 Gloomy or minor changes in mood.
• 2 Mild but definite depression and distress eg.
  feelings of guilt loss of selfesteem.
• 3 Depression with inappropriate selfblame,
  preoccupied with feelings of guilt.
• 4 Severe or very severe depression, with guilt or
  selfaccusation.

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HoNOS

• 8. Alexs wife reported that the week prior to
  his overdose Alex had been very anxious about
  leaving the house. This occurred both on weekends
  when he needed to go to the shops and during the
  week when leaving for work. On three occasions he
  broke into a cold sweat and began to tremble.
  However his anxiety would eventually settle with
  his wifes reassurance.

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8. Other mental and behavioural problems

• Rate only the most severe clinical problem not
  considered at items 6 and 7 as follows specify
  the type of problem by entering the appropriate
  letter A phobic B anxiety C obsessivecompulsiv
  e D stress E dissociative F somatoform G
  eating H sleep I sexual J other, specify.
• 0 No evidence of any of these problems during
  period rated.
• 1 Minor nonclinical problems.
• 2 A problem is clinically present at a mild
  level, eg. patient/client has a degree of
  control.
• 3 Occasional severe attack or distress, with loss
  of control eg. has to avoid anxiety provoking
  situations altogether, call in a neighbour to
  help, etc. that is, a moderately severe level of
  problem.
• 4 Severe problem dominates most activities.

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HoNOS

• 9. Alexs wife, family and friends are very
  supportive of him. He has three children aged 13,
  9 and 6. The children are confused by the changes
  in their fathers behaviour but are otherwise
  happy and caring towards him. His wife is
  concerned about his recent withdrawal from family
  and friends.

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9. Problems with relationships

• Rate the patients most severe problem associated
  with active or passive withdrawal from social
  relationships, and/or nonsupportive, destructive
  or selfdamaging relationships.
• 0 No significant problems during the period.
• 1 Minor nonclinical problems.
• 2 Definite problems in making or sustaining
  supportive relationships patient complains
  and/or problems are evident to others.
• 3 Persisting major problems due to active or
  passive withdrawal from social relationships,
  and/or to relationships that provide little or no
  comfort or support.
• 4 Severe and distressing social isolation due to
  inability to communicate socially and/or
  withdrawal from social relationships.

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HoNOS

• 10. Alexs self care is adequate but his wife has
  had to assume control of complex tasks such as
  household budgeting and paying bills.

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10. Problems with activities of daily living

• Rate the overall level of functioning in
  activities of daily living (ADL) eg. problems
  with basic activities of selfcare such as
  eating, washing, dressing, toilet also complex
  skills such as budgeting, organising where to
  live, occupation and recreation, mobility and use
  of transport, shopping, selfdevelopment, etc.
  Include any lack of motivation for using
  selfhelp opportunities, since this contributes
  to a lower overall level of functioning. Do not
  include lack of opportunities for exercising
  intact abilities and skills, rated at Item 11 and
  Item 12.
• 0 No problems during period rated good ability
  to function in all areas.
• 1 Minor problems only eg. untidy, disorganised.
• 2 Selfcare adequate, but major lack of
  performance of one or more complex skills (see
  above).
• 3 Major problems in one or more areas of
  selfcare (eating, washing, dressing, toilet) as
  well as major inability to perform several
  complex skills.
• 4 Severe disability or incapacity in all or
  nearly all areas of selfcare and complex skills.

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HoNOS

• 11. Alex and his family live in a comfortable 4
  bedroom house which they fully own. The home is
  close to all amenities and only about 20 minutes
  from where Alex is employed.

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11. Problems with living conditions

• Rate the overall severity of problems with the
  quality of living conditions and daily domestic
  routine. Are the basic necessities met (heat,
  light, hygiene)? If so, is there help to cope
  with disabilities and a choice of opportunities
  to use skills and develop new ones? Do not rate
  the level of functional disability itself, rated
  at Item 10.
• NB Rate patients usual accommodation. If in
  acute ward, rate the home accommodation. If
  information not obtainable, rate 7.
• 0 Accommodation and living conditions are
  acceptable helpful in keeping any disability
  rated at Item 10 to the lowest level possible,
  and supportive of selfhelp.
• 1 Accommodation is reasonably acceptable although
  there are minor or transient problems (eg. not
  ideal location, not preferred option, doesnt
  like food, etc.).
• 2 Significant problems with one or more aspects
  of the accommodation and/or regime (eg.
  restricted choice staff or household have little
  understanding of how to limit disability, or how
  to help develop new or intact skills).
• 3 Distressing multiple problems with
  accommodation (eg. some basic necessities
  absent) housing environment has minimal or no
  facilities to improve patients independence.
• 4 Accommodation is unacceptable (eg. lack of
  basic necessities, patient is at risk of
  eviction, or roofless, or living conditions are
  otherwise intolerable making patients problems
  worse).

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HoNOS

• 12. Alex has been employed by the bank for more
  than 10 years and is a highly valued and
  respected employee. Although concerned by his
  behaviour, his manager is supportive and is
  prepared to allow Alex to take extended leave if
  necessary.

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12. Problems with occupation and activities

• Rate the overall level of problems with quality
  of daytime environment. Is there help to cope
  with disabilities, and opportunities for
  maintaining or improving occupational and
  recreational skills and activities? Consider
  factors such as stigma, lack of qualified staff,
  access to supportive facilities, eg. staffing and
  equipment of daycentres, workshops, social clubs,
  etc. Do not rate the level of functional
  disability itself rated at Item 10. NB Rate the
  patients usual situation. If in acute ward, rate
  activities during period before admission. If
  information not available, rate 7.
• 0 Patients daytime environment is acceptable
  helpful in keeping any disability rated at Item
  10 to the lowest level possible, and supportive
  of selfhelp.
• 1 Minor or temporary problems eg. late pension
  cheques, reasonable facilities available but not
  always at desired times etc.
• 2 Limited choice of activities eg. there is a
  lack of reasonable tolerance (eg. unfairly
  refused entry to public library or baths etc.)
  or handicapped by lack of a permanent address or
  insufficient carer or professional support or
  helpful day setting available but for very
  limited hours.
• 3 Marked deficiency in skilled services available
  to help minimise level of existing disability no
  opportunities to use intact skills or add new
  ones unskilled care difficult to access.
• 4 Lack of any opportunity for daytime activities
  makes patients problem worse.

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Test Yourself

• Go to
• www.mhidp.health.wa.gov.au/one/resources_vignette.
  asp
• Listen and rate the vignettes
• Compare your ratings with the consensus ratings

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Bill is 27 y.o. and suffers Sz

• 1. Became extremely frightened of boarding house
  manager, threatened her with a knife. Assaulted
  police with fists when they came in response to
  threats.
• 2. Bill's mother reports that Bill threatened
  suicide three times in the last week, but soon
  after admitted that they were hollow threats. In
  a frank exchange Bill said that in the past week
  "I thought about suicide a couple of times, but
  dismissed it straight away."
• 3. Given recent events, Bill has become drunk
  four times in the past week. He abused his mother
  whilst intoxicated, she became angry with him and
  discontinued her daily visits to his boarding
  house. He missed two appointments with his GP
  because of severe hangovers. The loss of his
  carer and the failure to see his GP were major
  factors in Bill's decline in health.
• 4. Often unsure where he is. Speech is difficult
  to understand at times, but not incomprehensible.

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Bill (Cont.)

• 5. Moderate degree of withdrawal emergent tremor
  developed over last week. Was completely
  unaffected 7 days ago, but by yesterday was
  having difficulty using his favourite video game.
  Still no trouble dressing, eating and drinking
  (when he feels like it).
• 6. Suffering from paranoid delusions believed
  that boarding house manager was trying to kill
  him as part of a plot by Mossad, the Israeli
  secret service. Also believes that the ABC news
  team is trying to make him commit suicide, is
  extremely frightened of these threats.
• 7. Is "feeling low" at the moment, but not a
  clinically significant problem.

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Bill (Cont.)

• 8. No other problems.
• 9. He is very lonely, having lost most of his
  friends when he first became ill and not had the
  opportunity to make new ones. Recently, delusions
  have meant that Bill has completely withdrawn
  from friends and family.
• 10. Food, shelter etc. are provided. During this
  current psychotic episode Bill has only eaten
  potato crisps, drunk nothing but Coke and has not
  washed or changed his clothes. He has not gone to
  work or to the shops and has been so frightened
  by his delusions that he has only left his room
  to go to the toilet down the hall.

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Bill (Cont.)

• 11. Lives in good, affordable boarding house near
  to mother and Community Health Centre. However,
  boarding house manager uncomfortable with a
  schizophrenic boarder. Will not repair broken
  heater, wakes Bill up with loud noises at night,
  repeatedly threatens eviction etc.. Highly
  disruptive and distressing situation for Bill.
• 12. Bill has a part time job with an
  understanding employer (as a removalist) and has
  been to a number of educational and recreational
  workshops at his local Community Health Centre.

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Edna is forty-two years old. She suffers from
Bipolar disorder.

• Recent manic behaviour was brought to the
  attention of her doctor when her son called to
  say that Edna was "acting up again ... running
  around and making a fool of herself". He reports
  that she has been occasionally impatient with
  others, sometimes leading to verbal, but not
  physical arguments.
• On assessment Edna was agitated and distractible,
  felt full of energy, her speech was rapid and she
  jumped from topic to topic. She had slept little
  in the past 3 days due to being busy with her
  business interests.
• Edna has the firm and enduring delusion that she
  is 18 years old. Delusional behaviour seriously
  affecting social standing. Believes that she is
  Poppy King, a young female entrepreneur
  specialising in cosmetic products. Has bought
  large quantities of Ms King's product and is
  giving them away to anyone who will take them.
• Friends report that they are completely unable to
  communicate with Edna. She says that they are all
  "old fogies" and won't have anything to do with
  them at all. No contact with family either,
  claims that they are "small minded and boring".

35
Simon is 25 y.o.

• Simon has a 4-yr history of persisting depression
  coupled with alcohol dependence. He reports
  currently feeling so terribly depressed and
  miserable that he has reached the end of his
  tether. Over the last few weeks Simon has been
  increasingly troubled by thoughts of
  self-reproach and blame regarding recent and past
  behaviour. In the past week he cant stop
  thinking about his relationship with his father
  who died some years ago and on a few occasions
  these persistent reproachful ruminations have
  reduced him to tears. On several occasions, he
  has had thoughts of ending it all. These thoughts
  quickly disappeared though and he has not
  seriously considered doing this. He suffers from
  extreme lethargy, low energy, indecisiveness,
  procrastination, insomnia, and poor memory and
  concentration. Anne, his partner of 1yr, reports
  Simon is frequently forgetting peoples names and
  at a party they attended last week did not
  recognise a friend he had known for years.

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Simon (Cont.)

• He reports that over the years his appetite has
  been variable and he experienced frequent
  carbohydrate cravings with consequent weight
  fluctuations. At present he says he has no
  appetite at all and states that he has lost about
  5 kilos in the last month. Simon suffers from
  headaches, and stomach and back pains on most
  days. He complained that on several in the last
  two weeks he has decided to stay in bed because
  of these problems. On most days though he is up
  and about, despite feeling poorly.

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Simon (Cont.)

• Simon reports drinking a bottle of rum a day. He
  usually starts mid morning and keeps the bottle
  nearby until it is finished which is usually
  around early evening. When the rum is finished
  Simon drinks beer - usually a six pack before
  going to bed at night. He says that he has been
  having a lot of trouble sleeping at night and the
  beer helps him to sleep better. He told me that
  he used to only need a couple of extra beers a
  night to help him sleep but lately that has not
  been enough. He also said that when he has tried
  to stop drinking or to cut back, he felt lousy.
  He would sweat and tremble, the insomnia got
  worse, he became extremely anxious and restless,
  and he suffered from nausea.

38
Simon (Cont.)

• Simon stated that when under the influence of
  alcohol, he often becomes verbally abusive and
  occasionally physically abusive to Anne. Ten days
  ago he beat her so badly she ended up in the
  hospital emergency department. After this
  incident she told him she had had enough and that
  if he hit her again she would leave. Anne is icy
  and unsympathetic to Simon though she remains
  hopeful that he will improve and they can stay
  together. Simon is remorseful about his violence
  to Anne and desperately hopes that his
  relationship can be rebuilt. Simon has family
  members and some friends who keep in touch by
  phone or occasional visits. He is generally happy
  with the quality of his social relationships
  though concerned as mentioned about his
  relationship with Anne.

39
Simon (Cont.)

• Simon has been unemployed for two years and is
  drawing social security benefits. Over this
  period he has had several jobs but has been
  unable to keep them due to poor work performance
  and frequent non-attendance. He shares a small,
  sparsely furnished, suburban flat with Anne. At
  present the rent is in arrears and the landlord
  has threatened eviction. He has told Simon that
  he is getting fed up with the rent always being
  late and that the neighbours have been
  complaining about the noise and behaviour from
  Simons apartment.
• Simons self care is poor. He relies entirely on
  Anne for his meals and laundry. His spending on
  alcohol has led to problems with rent and other
  bills. Simon has no delusions or hallucinations.

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Margo 38 yo mother of two, home duties. Panic
Disorder with Ag.

• Margo is unable to go outside without the
  assistance of her husband or her mother (who
  comes twice a week to take her shopping). She
  will not answer the door when someone knocks on
  it. She has always been a quiet person, so this
  restriction on public outings does not dominate
  her life completely. Indeed, she was quite happy
  in the past and has only sought treatment because
  she feels she is not fulfilling her role as a
  mother as well as she might. When in a public
  place Margo reports that her anxiety makes her
  "mind go blank for long periods...I have to
  concentrate really hard to remember where I am
  going, what I came here for, what to do next, and
  things like that. I often forget to buy things at
  the shops because I'm so nervous".

41
Margo (Cont.)

• Consistently and markedly depressed, reports that
  "I feel terrible a lot of the time...I can't stop
  thinking that I should be taking my eldest
  (child) to school, doing the shopping and things
  like that". She does not display any signs of
  physical or mental slowness or agitation. Has
  occasional visits to see old friends (when
  accompanied on journey by husband) and is visited
  by a neighbour fairly regularly. Rarely able to
  make new friends, but has recently become
  friendly with a friend the neighbour introduced
  to her. However, Margo had few close friends
  before she became ill and prefers the company of
  her family (with whom she has a good
  relationship). Consequently, the difficulty in
  meeting new people does not overly concern Margo.

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Margo (Cont.)

• Lives in comfortable family home in location of
  choice. Margo happy in role as mother. All social
  opportunities available to her cohort are also
  available to Margo, there is a local Adult
  Education Program and an "Agoraphobia Sufferer's
  Group" in her region which she would like to
  attend, but her fears have so far prevented her
  from doing so. No hallucinations or delusions. No
  aggressive behaviour. Has burn on right hand
  spilled hot water on it two days ago whilst
  preparing a meal. Bumped the handle of a pot
  which tipped the water onto her hand resulting in
  blisters and daily bandaging by her husband.
  Smokes 40 cigarettes per day, no reported health
  effects to date.

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HoNOS Factor Structure

• Newnham, Harwood, Page (submitted)

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Mental Health Research Development Strategy (NZ)
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