General Behavior Inventory

The General Behavior Inventory (GBI) is a 73-question psychological self-report assessment tool designed by Richard Depue[1] and colleagues to identify the presence and severity of manic and depressive moods in adults, as well as to assess for cyclothymia. It is one of the most widely used psychometric tests for measuring the severity of bipolar disorder and the fluctuation of symptoms over time. The GBI is intended to be administered for adult populations; however, it has been adapted into versions that allow for juvenile populations (for parents to rate their offspring), as well as a short version that allows for it to be used as a screening test.

General Behavior Inventory
Purposeidentify manic mood
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General Behavior Inventory Version Development

General Behavior Inventory (GBI)

The GBI was originally made as a self-report instrument for college students and adults to use to describe their own history of mood symptoms. The original item set included clinical characteristics and associated features in addition to the diagnostic symptoms of manic and depressive states in the current versions of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. The first set of 69 items was increased to 73, with the final version having 73 mood items and 6 additional questions to check the validity of responses (but which did not figure in the scale scores). The self report version of the GBI has been used in an extensive program of research, accruing evidence of many facets of validity. Because of its length and high reading level, there also have been many efforts to develop short forms of the GBI.

7 Up 7 Down Inventory (7U7D)

The 7 Up-7 Down (7U7D) [2] is a 14-item measure of manic and depressive tendencies that was carved from the full length GBI. This version is designed to be applicable for both youths and adults, and to improve separation between both mania and depressive conditions. It was developed via factor analysis from nine separate samples pooled into two age groups, ensuring applicability for use in youth and adults.[2]

A sleep scale also has been carved from the GBI, using the seven items that ask about anything directly related to sleep.

Parent report on the GBI (P-GBI)

The P-GBI[3] is an adaptation of the GBI, consisting of 73 Likert scale items rated on a scale from 0 ("Never or Hardly Ever") to 3 ("Very often or Almost Constantly"). It consists of two scales: a depressive symptoms (46 items) and a hypomanic/biphasic (mixed) symptoms (28 items).[4]

Parent short forms
Parent GBI-10-Item Mania Scale
SynonymsPGBI-10M
LOINC62720-8

Again, due to the length of the full version, several short forms have been built and tested in multiple samples that may be more convenient to use in clinical work. These include 10 item mania, two alternate 10 item depression forms, and the seven item Sleep scale. All have performed as well or better than the self-report version when completed by an adult familiar with the youth's behavior (typically a parent).

The PGBI-10M [4] is a brief (10-item) version of the PGBI that was validated for clinical use for patients presenting with a variety of different diagnoses, including frequent comorbid conditions. It is administered to parents for them to rate their children between ages 5–17. The 10 items include symptoms such as elated mood, high energy, irritability and rapid changes in mood and energy as indicators of potential juvenile bipolar disorder.[4] The PhenX Toolkit uses this instrument as its child protocol for Hypomania/Mania Symptoms.[5]


Teacher Report on the GBI

One study had a large sample of teachers complete the GBI to describe the mood and behavior of youths age 5 to 18 years old. The results indicated that there were many items that teachers did not have an opportunity to observe the behavior (such as the items asking about sleep), and others that teachers often chose to skip. Even after shortening the item list to those that teachers could report about, the validity results were modest even though the internal consistency reliability was high. The results suggested that it was challenging for teachers to tell the difference between hypomanic symptoms and symptoms attributable to attention-deficit/hyperactivity disorder, which is much more common in the classroom. The results aligned with findings from a large meta-analysis that teacher report had the lowest average validity across all mania scales compared to adolescent or parent report on the same scales.[6] Based on these results, current recommendations are to concentrate on parent and youth report, and not use teacher report as a way of measuring hypomanic symptoms in youths.

Psychometric properties
This image illustrates the GBI's abilities in the three "P"s: (a) Predicting a diagnosis or criterion of importance; (b) Prescribing a specific treatment; and (c) helping us understand developmental Processes.

The GBI has been used extensively in research, including clinical samples, college students, longitudinal, treatment, and other studies. However, no normative data exist to calibrate scores in the general population.

Reliability

The GBI has exceptionally high internal consistency because it has long scales with a large number of items . The GBI shows high reliability whether completed as a self report or as a caregiver report about youth behavior .

Retest reliability also is good over a week or two week period, although the GBI's length makes it tedious to complete frequently .

Evaluating scores from the General Behavior Inventory against the EBA rubric for norms and reliability
CriterionRatingExplanation with references
NormsAdequateMultiple convenience samples and research studies, including both clinical and nonclinical samples[6]
Internal consistencyExcellent; too good for some contextsCronbach's alphas routinely over .94 for both scales, suggesting that scales could be shortened for many uses[7]
Inter-rater reliabilityNot applicableDesigned originally as a self-report scale; parent and youth report correlate about the same as cross-informant scores correlate in general[8]
Test-retest reliability (stability)Goodr = .73 over 15 weeks. Evaluated in initial studies,[9] with data also showing high stability in clinical trials[10]
RepeatabilityNot publishedNo published studies formally checking repeatability

Validity
Evaluation of validity and utility for the General Behavior Inventory (table from Youngstrom et al., unpublished, extended from Hunsley & Mash, 2008; *indicates new construct or category)
CriterionRatingExplanation with references
Content validityExcellentCovers both DSM diagnostic symptoms and a range of associated features[9]
Construct validity (e.g., predictive, concurrent, convergent, and discriminant validity)ExcellentShows convergent validity with other symptom scales, longitudinal prediction of development of mood disorders,[11][12][13] criterion validity via metabolic markers[9][14] and associations with family history of mood disorder.[15] Factor structure complicated;[9][16] the inclusion of “biphasic” or “mixed” mood items creates a lot of cross-loading
Discriminative validityExcellentMultiple studies show that GBI scores discriminate cases with unipolar and bipolar mood disorders from other clinical disorders[9][17][18] effect sizes are among the largest of existing scales[6]
Validity generalizationGoodUsed both as self-report and caregiver report; used in college student[16][19] as well as outpatient[17][11][3] and inpatient clinical samples; translated into multiple languages with good reliability
Treatment sensitivityGoodMultiple studies show sensitivity to treatment effects comparable to using interviews by trained raters, including placebo-controlled, masked assignment trials[20][21] Short forms appear to retain sensitivity to treatment effects while substantially reducing burden[21][22]
Clinical utilityGoodFree (public domain), strong psychometrics, extensive research base. Biggest concerns are length and reading level. Short forms have less research, but are appealing based on reduced burden and promising data

Interpretation

GBI Scoring

The current GBI questionnaire includes 73 Likert-type items which reflect symptoms of different moods. The original version of the GBI used case scoring where items were given values ranging from 1-4. Symptoms that were rated as 1 or 2 were considered to be absent and symptoms rated as 3 or 4 were considered to be present. However, if each item were to receive one of four scores, the authors of the GBI decided Likert scaling would be a better scoring option. The items on the GBI are now scaled from 0-3 rated as 0 (never or hardly ever present), 1 (sometimes present), 2 (often present), and 3 (very often or almost constantly present).[18]

PGBI-10M

For the PGBI-10M, the scores from each question are added together to form a total score, with higher scores indicating a greater severity of symptoms. Scores range from 0 to 30. Low scores of 5 and below indicate a very low risk of a bipolar diagnosis. High scores of 18 and over indicate a high risk of a diagnosis of bipolar disorder, increasing the likelihood by a factor of seven or greater.[23][4] Several peer-reviewed research studies support the P-GBI as a reliable and valid measure of bipolar in children and adolescents.[4][24] It is recommended to be used as part of an assessment battery in the diagnosis of juvenile bipolar disorder.

Limitations

The GBI is free for use clinically and in research. The reading level and length make it challenging for some people to complete. Being a self-report questionnaire, the GBI is not known to have any adverse effects on patients beyond the potential of causing minor distress.

Research

Shorter versions of the GBI have been validated for research and clinical use. For instance, the PGBI-10M is currently being tested as part of a large longitudinal study investigating the course of early symptoms of mania in children , with preliminary studies indicating its clinical efficacy in differentiating juvenile bipolar disorder from youth with other diagnoses .

See also

References
  1. "Richard Depue: Human Ecology Bio Page". Cornell University College of Human Ecology. Archived from the original on 18 September 2017.
  2. Youngstrom, Eric A.; Murray, Greg; Johnson, Sheri L.; Findling, Robert L. (1 December 2016). "The 7 Up 7 Down Inventory: A 14-item measure of manic and depressive tendencies carved from the General Behavior Inventory". Psychological Assessment. 25 (4): 1377–1383. doi:10.1037/a0033975. ISSN 1040-3590. PMC 3970320. PMID 23914960.
  3. Youngstrom, Eric A.; Findling, Robert L.; Danielson, Carla Kmett; Calabrese, Joseph R. (June 2001). "Discriminative validity of parent report of hypomanic and depressive symptoms on the General Behavior Inventory". Psychological Assessment. 13 (2): 267–276. doi:10.1037/1040-3590.13.2.267. PMID 11433802.
  4. Youngstrom, Eric A.; Frazier, Thomas W.; Demeter, Christine; Calabrese, Joseph R.; Findling, Robert L. (May 2008). "Developing a Ten Item Mania Scale from the Parent General Behavior Inventory for Children and Adolescents". Journal of Clinical Psychiatry. 69 (5): 831–9. doi:10.4088/jcp.v69n0517. PMC 2777983. PMID 18452343.
  5. "Protocol Overview: Hypomania/Mania Symptoms - Child". PhenX Toolkit, Ver 19.0. RTI International. 17 January 2017.
  6. Youngstrom, Eric A.; Genzlinger, Jacquelynne E.; Egerton, Gregory A.; Meter, Anna R. Van (16 November 2015). "Multivariate meta-analysis of the discriminative validity of caregiver, youth, and teacher rating scales for pediatric bipolar disorder: Mother knows best about mania". Archives of Scientific Psychology. 3 (1): 112–137. doi:10.1037/arc0000024. ISSN 2169-3269.
  7. Streiner, David L. (1 June 2003). "Being Inconsistent About Consistency: When Coefficient Alpha Does and Doesn't Matter". Journal of Personality Assessment. 80 (3): 217–222. doi:10.1207/S15327752JPA8003_01. ISSN 0022-3891. PMID 12763696.
  8. Achenbach, TM; McConaughy, SH; Howell, CT (March 1987). "Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity". Psychological Bulletin. 101 (2): 213–32. doi:10.1037/0033-2909.101.2.213. PMID 3562706.
  9. Depue, Richard A.; Slater, Judith F.; Wolfstetter-Kausch, Heidi; Klein, Daniel; Goplerud, Eric; Farr, David (October 1981). "A behavioral paradigm for identifying persons at risk for bipolar depressive disorder: A conceptual framework and five validation studies". Journal of Abnormal Psychology. 90 (5): 381–437. CiteSeerX 10.1.1.380.4958. doi:10.1037/0021-843X.90.5.381. PMID 7298991.
  10. Findling, Robert L.; Youngstrom, Eric A.; Zhao, Joan; Marcus, Ron; Andersson, Candace; McQuade, Robert; Mankoski, Raymond (2012). "Respondent and item level patterns of response of aripiprazole in the acute treatment of pediatric bipolar I disorder". Journal of Affective Disorders. 143 (1–3): 231–235. doi:10.1016/j.jad.2012.04.033. PMID 23044285.
  11. Klein, Daniel N.; Dickstein, Susan; Taylor, Ellen B.; Harding, Kathryn (February 1989). "Identifying chronic affective disorders in outpatients: Validation of the General Behavior Inventory". Journal of Consulting and Clinical Psychology. 57 (1): 106–11. doi:10.1037/0022-006x.57.1.106. PMID 2925959.
  12. Mesman, Esther; Nolen, Willem A.; Reichart, Catrien G.; Wals, Marjolein; Hillegers, Manon H.J. (May 2013). "The Dutch Bipolar Offspring Study: 12-Year Follow-Up" (PDF). American Journal of Psychiatry. 170 (5): 542–549. doi:10.1176/appi.ajp.2012.12030401. PMID 23429906.
  13. Reichart, CG; van der Ende, J; Wals, M; Hillegers, MH; Nolen, WA; Ormel, J; Verhulst, FC (December 2005). "The use of the GBI as predictor of bipolar disorder in a population of adolescent offspring of parents with a bipolar disorder". Journal of Affective Disorders. 89 (1–3): 147–55. doi:10.1016/j.jad.2005.09.007. PMID 16260043.
  14. Depue, RA; Kleiman, RM; Davis, P; Hutchinson, M; Krauss, SP (February 1985). "The behavioral high-risk paradigm and bipolar affective disorder, VIII: Serum free cortisol in nonpatient cyclothymic subjects selected by the General Behavior Inventory". The American Journal of Psychiatry. 142 (2): 175–81. doi:10.1176/ajp.142.2.175. PMID 3970242.
  15. Klein, DN; Depue, RA (August 1984). "Continued impairment in persons at risk for bipolar affective disorder: results of a 19-month follow-up study". Journal of Abnormal Psychology. 93 (3): 345–7. doi:10.1037/0021-843x.93.3.345. PMID 6470321.
  16. Pendergast, Laura L.; Youngstrom, Eric A.; Brown, Christopher; Jensen, Dane; Abramson, Lyn Y.; Alloy, Lauren B. (2015). "Structural invariance of General Behavior Inventory (GBI) scores in Black and White young adults". Psychological Assessment. 27 (1): 21–30. doi:10.1037/pas0000020. PMC 4355320. PMID 25222430.
  17. Danielson, CK; Youngstrom, EA; Findling, RL; Calabrese, JR (February 2003). "Discriminative validity of the general behavior inventory using youth report". Journal of Abnormal Child Psychology. 31 (1): 29–39. doi:10.1023/A:1021717231272. PMID 12597697.
  18. Findling, RL; Youngstrom, EA; Danielson, CK; DelPorto-Bedoya, D; Papish-David, R; Townsend, L; Calabrese, JR (February 2002). "Clinical decision-making using the General Behavior Inventory in juvenile bipolarity". Bipolar Disorders. 4 (1): 34–42. doi:10.1034/j.1399-5618.2002.40102.x. PMID 12047493.
  19. Alloy, LB; Abramson, LY; Hogan, ME; Whitehouse, WG; Rose, DT; Robinson, MS; Kim, RS; Lapkin, JB (August 2000). "The Temple-Wisconsin Cognitive Vulnerability to Depression Project: lifetime history of axis I psychopathology in individuals at high and low cognitive risk for depression". Journal of Abnormal Psychology. 109 (3): 403–18. doi:10.1037/0021-843x.109.3.403. PMID 11016110.
  20. Findling, RL; Youngstrom, EA; McNamara, NK; Stansbrey, RJ; Wynbrandt, JL; Adegbite, C; Rowles, BM; Demeter, CA; Frazier, TW; Calabrese, JR (January 2012). "Double-blind, randomized, placebo-controlled long-term maintenance study of aripiprazole in children with bipolar disorder". The Journal of Clinical Psychiatry. 73 (1): 57–63. doi:10.4088/jcp.11m07104. PMID 22152402.
  21. Youngstrom, E; Zhao, J; Mankoski, R; Forbes, RA; Marcus, RM; Carson, W; McQuade, R; Findling, RL (March 2013). "Clinical significance of treatment effects with aripiprazole versus placebo in a study of manic or mixed episodes associated with pediatric bipolar I disorder". Journal of Child and Adolescent Psychopharmacology. 23 (2): 72–9. doi:10.1089/cap.2012.0024. PMC 3696952. PMID 23480324.
  22. Ong, ML; Youngstrom, EA; Chua, JJ; Halverson, TF; Horwitz, SM; Storfer-Isser, A; Frazier, TW; Fristad, MA; Arnold, LE; Phillips, ML; Birmaher, B; Kowatch, RA; Findling, RL; LAMS, Group (1 July 2016). "Comparing the CASI-4R and the PGBI-10 M for Differentiating Bipolar Spectrum Disorders from Other Outpatient Diagnoses in Youth". Journal of Abnormal Child Psychology. 45 (3): 611–623. doi:10.1007/s10802-016-0182-4. PMC 5685560. PMID 27364346.
  23. "Table of all screening tools and rating scales". Massachusetts General Hospital: School Psychiatry Program and MADI Resource Center. Massachusetts General Hospital. Archived from the original on 27 September 2015. Retrieved 22 September 2015.
  24. Youngstrom, E; Meyers, O; Demeter, C; Youngstrom, J; Morello, L; Piiparinen, R; Feeny, N; Calabrese, JR; Findling, RL (December 2005). "Comparing diagnostic checklists for pediatric bipolar disorder in academic and community mental health settings". Bipolar Disorders. 7 (6): 507–17. doi:10.1111/j.1399-5618.2005.00269.x. PMID 16403176.

GBI form

Practice parameters

For youth

For adults

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